Pakistan as a whole, especially some of the regions in the provinces of Sindh and Baluchistan, are facing a period of extended drought for the last 5 years. The drought - resulting from below average rainfall and the resulting depletion of the surface and ground water - has affected severely the livestock, agriculture and human life.

The United Nations, in order to assess the situation resulting from drought and the requirements and needs of the government to cope with the situation, decided to send a mission to the two most affected provinces. The mission was split into food and non-food components. The non-food assessment was to focus on the assessment of the health and nutrition status of the people, especially women and children and situation regarding water. The non-food team consisted of staff members from UNICEF, WHO and UNDP:

The following participated in the preparation of the Mission:

1. Dr. T.O. Kyaw-Myint, UNICEF Team Leader

2. Dr. Faizullah Kakar, WHO Public Health
3. Mr. Zafar Iqbal, UNDP
4. Dr. Saba Mebrahtu, UNICEF Nutrition
5. Dr. Syed Zulfikar Ali, UNICEF Public Health
6. Mr. Birendra Shrestha, UNICEF Water & Sanitation
7. Mr. Masroor Ahmad, UNICEF Water and Sanitation

The fieldwork for the assessment was carried out by different teams in the two provinces and therefore separate provincial reports have been prepared for Sindh and Baluchistan.

Fieldwork in Balochistan was carried out from 16^th. to 21^st. April 2001 by the following:

1. Dr. T.O. Kyaw-Myint
2. Dr. Syed Zulfikar Ali
3. Engr. Muhammmed Arshad, Consultant UNICEF (WatSan)
4. Mr. Muhammad Anwar Panazai, Co-Ordinator, SCSPEB (NGO Quetta)

Dr. Badini WHO, who was to join the Mission, could not because of his commitment to monitor the National Immunization days from 17 to 19 April 2001.

The team traveled to the following areas:

1. District Qila Saifullah

• Muslim Bagh
• Kakar Kharosan: Mir Afzal Karez, Aishwat, Toraman Zakriazai

1. District Zhob:

• Bandhar
• Qamar Din Karez

1. District Loralai:

• Toda Murgha

1. District Ziarat:

• Zargai

1. District Pishin:

• Rod Mullazai

1. District Khuzdar:

• Aranjee and Nal

1. Kharan:

• Basima

The districts, tehsil and subtehsil visited were areas where drought was worst in 2000 and assessment done on the water availability, disease prevalence and the nutritional status of women and children.

Muslim Bagh and Kakar Khorasan in District Qila Saifullah were visited as these areas were visited by the non-food mission of the UN in 2000. Dr. Zulfikar Ali of the present team was also a member of the mission in May 2000. Dr. Zulfikar observed that there were sheep, goats and camels grazing who seemed to be in much better condition than those observed in 2000. He also noticed the absence of any congregation of new arrivals near towns, cities and villages, unlike in the previous year.

Throughout the travel along the Afghan border for about 800 kilometers, caravans of Afghanis were seen traveling back into Afghanistan, as was the usual migration of nomads at the end of the cold season.

Aranjee was the area where drought was reported in the media in 2000 and was 170 km. Away from Khuzdar District headquarters.

Toda Murgha in Loralai District was the area where there was the first outbreak of Congo-Crimean Haemorrhagic Fever with fatalities among the patients in 2000.

It was raining in all districts during the period of assessment in all districts from the Northern most areas in Qila Saifullah up to the Southeast region of Aranjee.

Health status:

This was assessed through visit to District Headquarters Hospitals, Tehsil Headquarter Hospitals, Rural Health Centres and Basic Health Units.

The hospitals’ bed occupancies were about 50% only, as was the case at this time of the year during the previous non-drought years and out-patients departments were not over-burdened with large number of patients.

Discussions were held with attending medical staff and the hospital records available were reviewed. As was noted in the non-food assessment report in 2000, the quality of information available was not complete to fully assess the disease burden and trends over time. But, the District Health Officers met felt that there were more cases of diarhoea and typhoid in April 2001 but not significantly higher than non-drought years and less than it was in April-May of 2000. The increase in numbers of patients seen in April was higher than each of the three months of the first quarter, which DHO attributed as normal, as attendance at facilities were much less in colder months e.g. no admission in the paediatric ward of Zhob hospital in December and January.

In the 2000 Social Assessment of Water Scarcity in Balochistan Report (UNDP conducted by Usman Qazi), the shift in patterns of health-seeking behavior was noted among the people surveyed. Gani noted that due to increasing poverty, people were using both public and private allopathic facilities less but were turning to the less expensive unani, traditional medicine or self-medication. Further investigation should be made along the same lines to see whether the low utilization of facilities was due to increasing poverty as reported last year or whether the trend was still the same between the last three years and this year as compared to the years prior to drought (The report is available on the Internet as www.usmanqazi.com)

Inquires were made specifically for TB, malaria, diarrhoea, acute respiratory infections and any cases which might be clinically diagnosed as Congo Crimean Haemorrhagic Fever (CCHF).

Records from the Tuberculosis clinic at Zhob and discussion with DHO and medical officer (TB) showed that only 19% of suspected cases of TB were confirmed as TB by sputum examination and the total number seen and followed up were determined by availability of free anti-TB drugs under the national TB Programme, rather than an actual increase in prevalence.

It was interesting to note that of the confirmed 240 cases of TB, the male female ratio was 1:2. This was a good indication of access and availability of services to women in the areas visited. Lack or inadequate access to TB treatment by women in TB programmes indicated poor social status of women in societies.

Malaria: although there were cases of severe and complicated malaria especially among children admitted to the health facilities (mainly cerebral malaria), case fatality was low as drug resistance was apparently not present in the various districts of Balochistan.

In areas with clay soil, where stagnant rainwater was present and in urban and periurban areas with stagnant wastewater, there was already increased breeding of mosquitoes and higher prevalence of malaria as compared to the dry porous areas of the various districts visited. It was only in Zhob District Headquarters that the local government could initiate mosquito control with fogging machines in 2000. The Political Agent Zhob voiced his concern that if there will be more rainfall this year and with non-availability of insecticide in 2001, there could be significantly higher numbers of malaria cases. He made a specific request as to the possibility of providing the relevant insecticide for fogging in malaria-prevalent areas of Zhob.

There were no reported outbreaks of diseases neither in the health facilities nor in the communities visited except in Aranjee. The District Commissioner (Khuzdar) reported an outbreak of cases of fever with rash in Aranjee. The team saw fourteen cases of children with this condition. All fourteen cases were examined together with ten children who had already recovered from the illness. The team leader, a pediatrician), diagnosed the cases clinically as measles and that it was an outbreak of measles but this was not agreed to by the DHO Khuzdar. Fever with rash, accompanied by ingested eyes, cough and chest infection, diarrhoea in acute cases with post-measles staining in the children who had recovered from the illness made the diagnosis of measles highly probable as the cause of this recent outbreak in Khuzdar.

Visit was made to Toda Murgha to communities where CCHF outbreak happened in 2000. The malik of the village was one of the fatal cases of CCHF during last year. The people interviewed seemed to be aware of the disease, which resulted in six deaths with the village community last year. The villagers made no report of any case resembling CCHF so far in 2001.

Nutritional Status of Women and Children:

As many children and women as possible were examined for nutritional deficiencies and chronic malnutrition.

For children under five years of age, Mid Upper Arm Circumference (MUAC) was used as the screening tool, with 13.5 cm. as the cut-off point. The prevalence of malnutrition in children was more among nomadic and rural communities and the status was much better in communities living in or near towns and larger villages.

Cases of Vitamin D deficiency were noted in some children which was expected in these communities where straddling of infants was a common practice.

The prevalence of malnutrition of all degrees i.e. 36% was not higher than the national average nor that of the average among Balochistan children found in nutrition surveys conducted in Pakistan before the three years of drought (National Nutrition Survey of Pakistan 1985).

It was difficult to examine the women, yet after much discussion and persuasion by the members of the NGOs who accompanied the mission, a number of women were allowed to have the weights and heights taken by the team. Body Mass Index (BMI) was calculated, as low BMI below 18.5 would indicate Chronic Energy Deficiency due to the effect of drought over the past three years.

Please note that the cut off point of 18.5 was used for the women examined based on the relative short stature of mean of 152 cm., range of 146 to 156 cms. and not 20 as used internationally for Western women with taller heights. The cutoff point of 18.5 has been used in Indonesia, Bangladesh and in South India with populations similar to that of communities in Balochistan. (Ref. Jane Kusin 1987: Chronic Energy Deficiency and Effect of Food Supplementation in Central Java).

Twenty nine percent of the small number of women examined had a BMI of less than 18.5 but none under the BMI of 16.5 which could be taken as the most severe form of Chronic Energy Deficiency.

Clinical anemia and presence of goitre could not be assessed as all women examined were wearing the "burka" which could not be removed at the time of examination.

Water:

At the time of the assessment, there was no apparent and significant shortage of water. Open wells, covered wells with hand pumps, gravity flow systems, shallow tube wells were examined and discussion made with the members of the communities.

Villagers reported that " it was easier to draw water from wells and tube wells" this year as compared to 2000 and that they had noticed an increase in the water level of open wells. They also reported not having difficulties in finding a water source within the grazing areas for their animals. Water could be very easily drawn from hand pumps tested by the team members without much effort.

All river and streambeds through which the team drove through had water in them but these might or might not remain if there be no more rain.

Although dried up apple and apricot trees were seen in some villages, there were more green, thriving and blossoming apple trees in orchards than dried withered ones. In areas where young saplings had been planted in place of the dead trees, these were also seen to be growing well.

A number of karez (natural and traditional water supply system from underground wells and underground aqueducts) were visited. Although water supply was low, the water was reported to be sufficient for drinking purposes in the villages around the karez systems. It was noted that it was possible to rehabilitate many karez this year to increase the water supply, as compared to last year.

Under the Khushal Pakistan in Balochsitan, with contribution from the Government of Balochistan and the communities, the following had been carried out:

Building of roads into the worst affected areas which would enable easier access to these areas this year than last year

1. Rehabilitation of karez and existing gravity flow systems: over 100 had been done and the government intend to rehabilitate up to 1000 of each system in 2001. Yet, this would not be enough to cover the scattered communities affected by drought.
2. Small dams: a number of small dams had been constructed for collection of rainwater. It was expected that it would take two to three years for these to contain enough water for communities living around and near them. The government provided bulldozers and land fill heavy equipment and communities provided labor and some cash contribution.
3. Windmills: 100 windmills for drawing of water from tube wells had been installed. These were at present in and around Quetta. All were functioning well. Unlike the previous tube wells which used diesel or electric pumps, the suction by these windmills were not too strong to deplete the ground water. The maintenance of these was minimal. Government of Balochistan planned to install and promote these windmill pumps more widely in Balochistan instead of the electric and diesel pumps being used at present.

Apart from the above, the Relief Commissioner had formed mobile teams for provision of health services to the remote communities. One of team had visited Noshki area during the week of the team’s visit

The Team observed that in spite of the government's restriction on sinking of more deep tube wells, many were found in the process of being sunk in areas where orchards were present. Each pump was calculated as pumping out 600 to 800 gallons of water per hour. As these pumps were running 24 hours a day, especially for electric pumps, there was concern by both the government and NGOs of further and rapid depletion of ground water in Balochistan.

During the drought of 2000, many tube wells were put in for communities (as well as at campsites). The tube wells, which were mostly in riverbeds, were poorly maintained and most of the hand pumps examined were out of order at present.

The growing problem of shortage of water in Balochistan was emphasized in the Balochistan Conservation Strategy developed and finalized in 2000 by the Government of Balochistan and International Union for the Conservation of nature, Pakistan (IUCN Pakistan). This document is available on the Internet as www.bcs.sdnpk.org. The main issue for Balochistan at present and in the future would be more of proper water management than finding more sources of water.

Conclusions and recommendations:

The Team concluded that although there were both identified and felt needs in health, nutrition and water:

1. the degree of these was not worse than May 2000, based on the Mission Report
2. the nutritional indicators, although not good, were still within the range of national averages
3. therefore, there would be no urgent need for provision of support on an emergency basis.

This was the opinion of the Additional Chief Secretary, the Relief Commissioner, the Deputy Commissioners, Political Agents and Assistant Commissioners met and interviewed.

All the senior and other government officials met felt that the effects of the last three years' drought had worsened the already existing poor health and nutritional status of the people of Balochistan. However they also expressed the opinion that there was a need to support the government efforts to improve the lot of the affected population on the basis of a long-term development strategy, rather than immediate emergency measures.

The observation of rainfall and a survey of water resources were being done by the Directorate of Water Resources who would be looking into viable options for provision of water and better management of water resources. NGOs members met in different districts, who worked with the government during last year drought also, expressed the need for technical assistance for water management and search for alternate options for safe water. It was noted that taking the aggregate rainfall of Balochsistan would not fully reflect the situation, as the level of rainfall differed widely from area to area within Balochistan (report of the Department of Water Resources 1994).

No increase in the influx of Afghanis was reported nor new settlements observed. Many Afghani nomads living in tent and mud communities near villages and towns were found to be emptying out as nomads were returning to Afghanistan. The Additional Chief Secretary (ACS) during the meeting also confirmed this observation.

ACS also informed the team about the need to assess the appropriateness of relief supplies provided during 2000. He thanked and appreciated the excellent response from donors but gave example of a large number of shoes for children; clothing and dresses not appropriate for wear by the women and children of Balochistan.

ACS asked UNICEF to review appropriateness of provision of blended food for children. He advised the Team to explore the possibility of producing blended food material that can then be prepared or ‘cooked’ within communities and camps by the mothers themselves. On the contrary, the Relief Commissioner informed the Team that initially there were reports of some problems in using of the blended food. However, with the help of NGOs, the women in camps were taught on how to use the blended food provided, after which the women found the blended food provided easy to use and acceptable by the children.

The Team would like to emphasize that the report contains observations made during the said period of the mission and the mission would not make any predictive conclusions on what might happen if there be no further rains in Balochistan.

Time constraint and inability to review information over the past few years to study trends resulted in the Team's inability to provide a more comprehensive assessment. It was expected that such similar short mission be conducted this year to observe any change in the rest of 2001.

The data collected by the consulting firm to assess the impact of drought (with UNDP's support) in 2000 was being analyzed by Mr. Usman Qazi and the report ensuing out of that exercise would be very informative for further planning.

Issues addressed in the Social Assessment of Drought in Balochistan 2000 (Usman Qazi) should be revisited.

These reports and the document of Balochistan conservation strategy should be reviewed to see where UN's support and intervention would be most critical and beneficial.

The Team Leader and the UN Non-Food Mission would like to thank the Government of Balochistan, the Additional Chief Secretary (Development), the Deputy Commissioners and Political Agents, the DHOs and medical staff of various health facilities, the NGOs who facilitated the contact with communities and made information gathering easier; and the people of various communities visited for their kind cooperation and hospitality.

Percentage under BMI 18.5 = 29%

SINDH:

In the province of Sindh, 5 districts have been declared as being affected by drought. These are Dadu, Thatta, Tharparkar, Sanghar and Mir pur Khas.

The districts visited during the Non-Food Assessment Mission were Dadu and Thatta. Dr Syed Zulfiqar Ali and Dr Asif Aslam from UNICEF were members of the mission. In district Thatta, Mr Aftab Nizamani of the District Education Office and Mr Rafiq Mangi, Program Coordinator, Indus Resource Center accompanied the Mission members. The assessment was carried out from April 25 to 27 by visiting the affected areas and meeting key officials of the government and NGOs, members of the community, visits to health facilities and assessment of the women and children by Body Mass Index (BMI) for women and Mid Arm Circumference for the children between the ages of six months to five years. This would indicate the affects of drought on their nutrition status.

1. Office of the Deputy Commissioner
2. Office of the District Education Officer
3. Civil Hospital, Makli Thatta
4. Goth Shafi Mohammad in the Kohistan Area
5. Village Mal Mari
6. SAZDA Dispensary, Mal Mari
7. Health House of LHW Benazir Jokhio

1. Taluka Hospital Sehwan
2. Office of Indus Resource Centre (NGO)
3. Village Bubak
4. Manchar Lake
5. Office of the Assistant Commissioner Sehwan
6. Health Center Jhangara

FINDINGS:

The drought situation in Sindh has been there for approximately seven years, with the two districts of Thata and Dadu receiving minimal rains during this period. The affects on the economic activity however are not very apparent as the dependence on livestock and/or agriculture is minimal. The people affected by drought mostly live in remote areas of the district and are thinly spread out. There is shortage of clean drinking water in these areas. While wells and other sources of water are available, the quality of water is very poor, it being brackish and unhygienic.

The diseases most commonly reported in these areas were TB, Malaria, Diarrhea and ARI (Acute Respiratory Tract Infections). There were reports of measles cases. The increase in the incidence of these diseases as a result of the drought could not be determined. Perusal of the records in the Health Centre Jhangara being run jointly by the govt., LASMO Oil Company and the Agha Khan University revealed that in the month of March 2001 there were 155 cases of Malaria, 2 cases of TB, 20 cases of Scabies, 41 cases of dysentery, 61 cases of diarrhea and 1114 cases of ARI were reported. The pattern remained approximately the same in the corresponding period of previous years also. The Medical Officer incharge informed us that Measles cases were also included in the ARI. Still an explanation for such a high proportion of ARI cases could not be determined. Perusal of the HMIS report and the OPD register revealed that while 35 cases of measles were reported in the HMIS monthly report from Dispensary Mal Mari for the month of February, the OPD register showed only 7 cases.

There has been migration of communities from certain villages in the districts reported. This was also established by the reports of reduction in the attendance and enrolment in schools in the two districts. Most of these people have been reported to have moved to areas where they can find jobs during the wheat harvesting season and in industries etc in towns.

The government has prepared reports on the situation arising from the drought and the support/inputs required (a copy of the plan prepared by the DC Thatta is attached). The government officials felt that in most cases, due to the remoteness of the regions affected and the thin density of the population, efforts to improve the infrastructure or provision of clean drinking water through deep tube wells may be very costly, while the benefits will be minimal. The government has, however, planned to provide basic needs such as rations, medical care etc.

The assessment of the nutritional status of the women and children based on the BMI and Mid Arm Circumference (MAC) is given below:

An area that requires special mention is that of Lake Manchar in district Dadu. Lake Manchar is reported to be approx. 120 sq. km. in area with an estimated 50,000 people living in the lake on boats and makeshift huts within the lake. The people living in the area are dependent upon the fishing in the lake. Their lives have also been affected by the drought as the water level has gone down considerably in the lake causing reduced yield of fish. Another factor is the ‘poisoning’ of the water in the lake due to opening of drains into the lake. The people reported TB as being the most common disease prevalent in the area. The Statistical Officer reported that in a recent exercise about 300 cases of tuberculosis were found out of a population of 5000. Other common diseases reported were diarrhea, malaria and night blindness.

RECOMMENDATIONS

1. Continuous follow-up & monitoring of the situation to offset any further deterioration in the situation especially in the hot summer season.
2. Repair and maintenance of the wells, hand pumps etc, as in some areas the wells and hand pumps are there but require cleaning out/maintenance.
3. Training of NGO and government staff in nutrition counseling of the members of the community.
4. Intensification of immunization activities in the affected areas through outreach.
5. Intensification of TB and malaria control measures especially in Manchar Lake area.