A school is meant to be a place where children learn, grow and prepare for the future. But for millions of children across Pakistan, some of the most basic conditions for healthy learning — clean drinking water, functional toilets, soap and regular health checks — remain uncertain.

Intestinal worms are often invisible, but their consequences are not. For children, an infection that may begin with contaminated water, unhygienic food, poor sanitation or inadequate handwashing can gradually affect nutrition, physical development, energy levels and concentration in the classroom.

Symptoms of a worm infection may include recurrent abdominal pain, weakness, fatigue, loss of appetite, nutritional deficiencies, iron deficiency anaemia and impaired physical growth. Hookworm infections are particularly associated with anaemia among young girls, although infection patterns can vary according to environmental and lifestyle conditions.

In this case, intestinal worms are more than a medical problem. They deprive children of nutrients, affect growth and make it harder to concentrate in the classroom. While school-based deworming programmes have reached millions of children, health experts caution that a dose of medicine cannot solve a problem that is repeatedly recreated by unsafe water, poor sanitation and inadequate hygiene.

The question, therefore, is not simply how many children receive deworming medicine, but whether schools are providing the conditions needed to keep them healthy after the medicine has been administered. Across Punjab, Sindh and Khyber-Pakhtunkhwa (K-P), accounts from students, parents, doctors and education and health officials point to gaps in facilities, monitoring and continuity that could undermine efforts to protect children from preventable infections.

Therefore, health experts and school administrations continue to confront a problem that extends beyond the simple provision of medicine. Deworming tablets may treat an existing infection, but without clean drinking water, functional toilets, soap, proper handwashing facilities and sustained health education, children remain exposed to the same conditions that can lead to reinfection.

A dirty dilemma

According to figures cited in Pakistan’s national soil-transmitted helminth survey, based on World Health Organisation (WHO) estimates, around 21.7 million school-age children and 9.3 million preschool children in Pakistan are infected with soil-transmitted helminths. WHO says such infections are particularly common in communities where sanitation and hygiene are inadequate. Globally, around 1.5 billion people are affected by these parasitic infections, with children among the groups most vulnerable to their effects.

The problem is particularly significant because school-based health programmes cannot reach every child. In Khyber-Pakhtunkhwa, for instance, the 2023 Population Census recorded 4.92 million children aged five to 16 as out of school, representing 37.49 per cent of children in that age group. The figure includes around 2.92 million girls and two million boys. The large number of children outside the formal education system presents an obvious challenge for programmes that rely on schools as the primary point of access.

The Interactive Research and Development (IRD) has been implementing a school-based deworming programme in Pakistan since 2019. According to its Pakistan Deworming Initiative (PDI), the programme has so far reached 25.3 million children. They told The Express Tribune that 26,753 schools in 22 districts of K-P are registered with the programme, covering both public and private educational institutions. It said the initiative was not limited to K-P, adding that the Balochistan government had also formally taken ownership of the programme.

Yet the question remains whether reaching millions of children through periodic campaigns is enough to break the cycle of infection. Public health experts maintain that medicine alone cannot address the environmental conditions that allow intestinal worms to persist. Improved sanitation, safe drinking water, handwashing facilities and hygiene education are equally important components of prevention.

In Punjab, this question assumes particular importance as the School Health and Nutrition Programme already provides a framework for screening children, raising awareness about health and hygiene and referring children to health facilities when necessary. What remains essential is determining how consistently these services translate into functioning facilities and measurable outcomes at school level.

Schools need to be examined not merely for whether they possess toilets or water points on paper, but whether children can actually use clean toilets, access safe drinking water, wash their hands with soap and receive timely health information. Equally important is the availability of district-wise records showing how many children are receiving deworming medicine, how many schools are covered and whether programmes are being repeated according to health requirements.

The hygiene gap

A toilet sign on a crumbling school wall means nothing when the water tap is bone-dry and the washbasin is covered in grime. Across the country, the illusion of school hygiene is quietly failing children, turning classrooms into breeding grounds for preventable infections both inside the gates and at the snack stalls outside.

In Punjab’s schools, the condition of basic facilities can determine whether a deworming programme addresses the problem or merely treats one stage of it. During reviews of public and private educational institutions, questions have emerged over whether toilets are clean, whether drinking water is continuously available, whether washbasins are functional and supplied with soap, and whether school administrations regularly conduct deworming programmes.

The distinction between having a facility and having a usable facility is significant. A water tap without safe water, a washbasin without soap or a toilet that is rarely cleaned may technically exist but offer limited protection against infection.

Students themselves have highlighted these gaps. Some students said that while their schools had water facilities, soap or adequate handwashing arrangements were not always available. Others reported that washrooms were not cleaned regularly. Some children said they had received deworming medicine but were not given sufficient information about its benefits or why the medicine was necessary.

For students, the connection between facilities and health is often straightforward. Many believe that consistently available clean drinking water, soap and clean washrooms could help prevent illness and make schools healthier places. When it comes to female students, the absence of clean and safe toilets, water and soap can create an additional burden, particularly during menstruation.

The problem is not restricted to Punjab. In Karachi, government schools have long faced complaints regarding sanitation, toilets, handwashing facilities and drinking water. According to Professor Dr Waseem Jamalvi, President of the Pakistan Paediatric Association Sindh, government-school toilets often lack proper cleanliness arrangements as well as soap and sanitiser. He described the absence of clean drinking water and proper toilet facilities at the primary-school level as a serious concern.

Private schools, according to Jamalvi, generally have better-maintained washrooms and handwashing facilities. However, differences between institutions mean that access to basic health and hygiene services cannot be assumed simply on the basis of whether a child attends a public or private school.

The situation becomes more complicated when children leave school premises. In Karachi, unhealthy food and drinks are frequently sold at roadside stalls around government schools. Brightly coloured beverages and other unhygienic food items may expose children to gastrointestinal problems, particularly where clean water and handwashing facilities are already inadequate.

Parents also face an information gap. Symptoms such as abdominal pain, loss of appetite and weakness may be dismissed as ordinary childhood problems, delaying medical examination. Health experts advise that children experiencing persistent symptoms should be medically assessed rather than being treated on assumptions.

Ayesha Tariq, a resident of PIB Colony, said her six-year-old son, Shayan, repeatedly complained of abdominal pain and loss of appetite and appeared restless at night. Initially, she did not associate the symptoms with intestinal worms and consulted a family physician. A stool test and other examinations subsequently confirmed the infection.

She said the experience made her realise that parents often underestimate the relationship between contaminated water, food, hand hygiene and intestinal infections. She advised parents to teach children to wash their hands before eating and after using the toilet, ensure drinking water is clean and safe, and provide hygienic food.

The mother of seven-year-old Rimsha, who was receiving treatment at the National Institute of Child Health (NICH), described a similar experience. Her daughter had suffered severe abdominal pain for around a month and had difficulty eating properly. Medical examinations, including blood and stool tests, detected intestinal worms and intestinal inflammation.

According to Rimsha’s mother, doctors linked her daughter’s illness to unhygienic food and contaminated water. She said the child frequently ate market food, including French fries, before developing health problems. The child was later admitted to the NICH emergency department, where she received treatment.

More than just a syrup

Treating children for intestinal infections while leaving them to navigate contaminated water, missing soap, and defunct health screenings is like bailing water from a sinking boat. Without clean facilities, routine checkups, and a continuous system of care, one syrup alone will never stop the cycle of reinfection.

Health experts say intestinal worm infections are closely associated with poor hand hygiene, contaminated drinking water, inadequate toilets and poor sanitation. For girls, the condition of school facilities has an additional importance. Clean and private toilets, adequate water and soap are essential for menstrual hygiene and dignity. Poor facilities can cause discomfort and may contribute to absenteeism during menstruation.

The lack of regular school health screening adds to the prob]lem. Karachi’s School Health Services programme, launched in 1987 with WHO and UNICEF cooperation, once provided routine medical examinations to schoolchildren. According to the report, 423 doctors were assigned to examine around 600,000 children. Female doctors were assigned to girls’ schools and male doctors to boys’ schools.

Students received medical examinations, hygiene education, dental checks and monitoring for nutritional deficiencies, weight problems and anaemia. The programme continued for about 25 years before being discontinued by the Health Department in 2012. Its closure left government schools without the same system of routine health screening, making it difficult to establish reliable data on intestinal worms and other illnesses.

Pakistan has conducted several phases of deworming through the Pakistan Deworming Initiative, reaching millions of children. However, more detailed district-level information is needed, particularly in Punjab, to determine how many public and private schools are covered, how many children receive treatment each year, and how many miss or decline the medicine.

Schools should maintain clear records of their deworming activities, including when the last campaign was conducted, how many children received medicine, how parents were informed and what instructions were given to staff.

Experts stress that deworming should not be treated as a one-time campaign. It needs to be linked with school health, nutrition, safe drinking water, sanitation and handwashing programmes. Regular monitoring of toilets, water points and handwashing facilities could help identify the conditions that allow infections to return.

Punjab’s School Health and Nutrition Programme provides a possible framework for this approach through health screening, hygiene awareness and referrals to healthcare facilities. However, reliable district-wise data is needed to measure how consistently these services are being provided.

Research involving schoolchildren in different parts of Punjab has also reported a significant prevalence of intestinal parasitic infections and linked them with sanitation, water quality, personal hygiene and socioeconomic conditions. Experts therefore emphasise that medicine alone cannot prevent reinfection. Deworming may remove worms, but it cannot provide clean water, soap or safe toilets.

The challenge is even greater for children who are out of school, particularly in K-P, because school-based programmes cannot reach children who are not enrolled or regularly attending classes. Karachi faces a different challenge because the discontinuation of school health services removed a system that once provided routine medical examinations to large numbers of children.

Experts also emphasise prevention at home. Parents should teach children to wash their hands with soap after using the toilet and before eating, provide clean drinking water, keep their nails trimmed and discourage children from putting soil or dirty objects into their mouths.

A deworming syrup can clear an infection, but it cannot stop the next one from taking hold. True protection requires clean water, safe toilets, soap, and regular health checks. Until these basics become the everyday reality inside every school, children will remain trapped in a relentless loop of preventable illness.