Pakistan’s stunting conundrum

KARACHI:

In Pakistan 40.2 per cent of children under five are stunted, which is an alarmingly high incidence, according to the National Nutrition Survey (NNS) 2018. The fact that this number has barely increased from the previous surveys suggests that the underlying causes of malnutrition are still not addressed.

Stunting is a serious public health concern. A reflection of long-term malnutrition, stunting impairs cognitive and physical development, which in turn impacts a child's potential and productivity. Despite numerous initiatives, Pakistan still struggles with high rates of childhood stunting.

There are significant differences between the provinces; Sindh and Balochistan have the highest rates of stunting (48 per cent and 46.6 per cent, respectively). Punjab and Khyber Pakhtunkhwa (KP) have marginally higher percentages at 36.4 per cent and 40.5 per cent, respectively. There are many socioeconomic and cultural circumstances across the nation that contribute to stunting are highlighted by these geographical variations.

“There are several factors that lead to stunting and not just poverty scales because the same scales cannot be used across the world. For example, earning one and a half or two dollars a day may take you out of the poverty line but what facilities are provided to the poor in the country?” said Dr Jai Das, assistant professor of paediatrics and child health and assistant director, IGHD.

Children's growth and development are impacted by poor dietary intake caused by food poverty. Across the country, poverty continues to be the primary cause of stunting. A sizable section of the population cannot buy enough food for nourishment and lives below the poverty line. The World Bank estimates that 24.3 per cent of Pakistanis are living below the country's poverty level.

The growth of a fetus depends on the mother's diet both before and throughout pregnancy. A large percentage of Pakistani mothers experience anemia and malnutrition, which affects fetal growth and causes low birth weight, which is a marker of stunting. The NNS 2018 reported 41.7 per cent of women of reproductive age to be anemic, and 14.4 per cent of women as underweight. “If the poor are earning two dollars a day then can they buy the same things they were able to buy five years ago,” asked Dr Das, adding that the buying capacity has changed drastically. If the numbers are to be believed, he said, then 40 per cent of the children under the age of five are stunted according to the surveys conducted in 2018, 50 per cent of adolescents are underweight, and children between the ages of 10-12 are also 20 per cent stunted according to the same survey. “Since then so much has changed. We have seen two floods, Covid, seasonal shifts and catastrophic climate change. The numbers right now will be alarming,” he said.

The rising cost of living, inflation, and food security can lead to many other issues as well. “With Pakistan being an agricultural country facing severe climate change effects, our productivity has been affected and so has the income. When there is not enough money to provide then malnutrition exists and it leads to stunting,” Dr Das explained.

Sharing an example of how such indices and indicators can’t help the local population, he said, “If the common understanding is that most of the stunting cases are in rural areas and not in urban centres, what definition of urban are we following? Even in a city like Karachi, there are places that are in worse conditions than rural areas.”

“The core definition of urban areas has changed because there are dwelling areas where the conditions are worse because in villages at least they have low-cost food or at least fresh fruits and vegetables to consume while in cities the cost and quality both are out of our control,” Dr Das shared.
A key cause of stunting is inappropriate feeding behaviours, which include delayed onset of nursing, low rates of exclusive breastfeeding, and inadequate supplemental eating. Just 48 per cent of newborns under six months old receive only breast milk, and additional feeding techniques frequently fall short in terms of quantity and quality.

Malnutrition is made worse by limited access to high-quality healthcare treatments. There are few healthcare facilities and a shortage of qualified healthcare professionals in many rural and isolated places. Additionally, children are more susceptible to diseases due to uneven vaccination rates, which worsens their nutritional state.
Inadequate hygiene and sanitation habits result in recurrent infections and illnesses like diarrhea which impede the absorption of nutrients and cause stunting. Only 36 per cent of people have access to safely managed drinking water, and 24 per cent of people defecate in the open, according to UNICEF.

Consequences of stunting

The effects of stunting are extensive, affecting not just the individual but also the community at large. Children with stunted immune systems are more vulnerable to infections and illnesses. Additionally, they have a larger chance of growing up to have chronic illnesses like diabetes and hypertension.

Cognitive problems result from the impact of stunting on brain development. Children who are stunted frequently have lower IQs, do badly in school, and have less education, which will limit their employment opportunities and financial possibilities in the future.
The financial toll that stunting takes is high. It lowers the human capital of the nation, which hinders economic growth and productivity. According to a study conducted by the Pakistan Institute of Development Economics (PIDE), malnutrition, including stunting, is estimated to cost Pakistan two to three per cent of its GDP annually.

“Stunting can be due to personal and socio-economic factors altogether, and there is no one solution to this as well,” Dr Das said, adding that other than malnutrition and lack of money, climate change plays a major part in today’s situation where due to environmental changes we face heat strokes, floods, typhoons, wildfires, storms and what not. All these bring instability, lack of food, livestock and wreak havoc in the lives of the people already living in marginalised conditions.

The cycle of hunger and poverty is perpetuated when stunted children grow up to be malnourished adults who in turn give birth to low birth weight children.

Government initiatives
The Pakistani government has started a number of initiatives to combat malnutrition. One such initiative is the Ehsaas Nashonuma Programme, which offers health services, nutrition education, and conditional cash transfers to women who are pregnant, nursing, and to children under the age of two.

Provincial programme manager, nutritional international, Hafeezullah Gambhir said, “Mega programs have been introduced by the Government of Sindh, such as Accelerated Action Programme (AAP) that ended last year after five years where the main motive was to reduce the numbers in Sindh from 48 per cent to 31 per cent which is the same as other South Asian countries.”

However, there are a number of implementation issues that these programs frequently encounter, such as inadequate finance, a lack of coordination between various sectors, and a restricted reach in rural areas.

“Other than environmental and poverty issues, awareness is also very important as stunting is not just related to poor people. The numbers suggest that 20 per cent are rich people while 44 per cent are poor from the total 48 per cent of children that are stunted in Sindh,” shared Gambhir.

Stunting is being fought in Pakistan by a number of non-governmental organisations and international groups. WASH activities, maternity and child health services, and nutritional programs are supported by Unicef, the World Food Programme (WFP), and other agencies. Although these initiatives have had good success at the local level, they need to be scaled up and integrated with national policy in order to have a larger impact.

The People's Primary Healthcare Initiative (PPHI) has played a significant role in Sindh in enhancing maternity and child health services. PPHI has improved immunisation rates and encouraged breastfeeding and complementary feeding practices through community-based interventions. The high proportion of poverty and food insecurity make it difficult to lower stunting rates even with these initiatives.

The Government of Sindh has also launched a multi-sectoral study to cater to issues such as disaster relief, where various sectors from environment to health and from food to education can be brought together.

Balochistan faces particular difficulties because of its rough terrain and dispersed population. The primary goals of the Balochistan Nutrition Programme for Mothers and Children (BNPMC) have been to promote good hygiene and supply vitamin supplements. However, logistical limitations and security concerns restrict the program's influence.

“The biggest and most logical programme for stunting is the 1,000 days program, which is also underway in other countries, in which mothers will be given nutritional diets starting from pregnancy to lactation periods,” Gambhir explained. Once the height and mental development develop, the condition cannot be reversed so the idea is to control it from the beginning. This programme ensures that a mother receives proper nutrition for transferring food, whether during pregnancy or breastfeeding, to her baby.

What can be done to reduce stunting?

It is imperative to enhance food security. Programs for social protection, agricultural measures to increase food production, and price stabilisation policies can all help achieve this. Access to wholesome food for vulnerable communities should be guaranteed by the government.
Maternal health and nutrition programs must be given top priority. Crucial actions include giving women access to healthcare services, educating them about appropriate meals, and providing vitamin supplements.

In terms of services and help, both urban and rural areas must be on the same page and no part of the country should be neglected. Among a few of the possible solutions is supplements but that too isn’t a long-term solution. “Dietary supplements can be given for cases of acute malnutrition or with severity of the health issue but that is not a long-term solution even if it’s provided free,” Dr Das shared.
It is critical to raise awareness of the benefits of breastfeeding and appropriate supplemental feeding. Health professionals must be prepared to assist and inform mothers. Programs that are rooted in the community can be extremely important in altering feeding habits.

“Awareness about nutritional use and balanced diet is important and cannot be neglected because stunting cases in rich families are also reported,” said Gambhir.

It is crucial to train healthcare professionals to provide high-quality maternity and child health services as well as to expand the healthcare infrastructure, particularly in rural areas. Improving the capacity of healthcare services to manage cases of malnutrition can lead to better results.

Infrastructure related to water, sanitation, and hygiene has to be invested in. Encouraging practices like washing your hands and consuming clean water can lower the frequency of diseases that cause stunting.
A multi-sectoral strategy combining the health, education, agricultural, and social protection sectors is needed to combat stunting. Integrated strategies and coordinated actions are required to address the many variables that contribute to stunting.

Pakistan needs dietary diversity to promote a balanced diet to people so they can consume better food and avoid stunting in the next generations. “More research is the need of the hour for indigenous fruits,” Dr Das said. “A larger level of research should be conducted across the country on the vegetables and fruits that are locally available in the areas, as each area has its own famously produced fruits and vegetables. This research can help in identifying which edible item has more protein, micronutrients and what advantage can be gained by consuming these,” he suggested, adding that locally produced fruits and vegetables can be less costly and easy to consume as well.

In Pakistan, stunting is still a serious public health concern that has negative effects on both people and society as a whole. More thorough and well-planned measures are required from the government, NGOs and foreign partners to address the core causes of stunting, which include poverty, food insecurity, maternal malnutrition, insufficient feeding practices, and subpar healthcare and WASH facilities. Pakistan can ensure a healthier and more productive future for its children by elevating stunting to a serious health and development issue.