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Immunization – Right of children

Unimmunised children continue to pose a challenge to health authorities

Right of children
Awareness needs to be raised among parents.

Like millions of mothers of Pakistan, it did not seem worth it to her to get her children vaccinated as that would make them temporarily sick. “Bacha beemaar ho jata hai; bukhaar charh jaata hai teekay se (The child becomes sick and develops a fever after vaccination).”

However, illiteracy is not the only factor that holds back Pakistani mothers from getting their children vaccinated. A lack of awareness about the importance of Routine Immunization (RI), and an absence of sensitisation regarding facts that dispel myths, seem to be present across the board. Across the road, there are children in upper tier homes in Karachi that have also not been vaccinated, or have not received follow-ups.

Marvi Junaid, a teacher, is an urban mother who, in her own words, is “confused” about vaccination. “I was stopped from getting my sons vaccinated after the initial shots; my husband studied it in detail and was convinced that this could be detrimental to the child’s immunity, and felt it was more of a money-making scheme,” says Marvi. She feels that religious notions also have a role in discouraging people against vaccination. “Even in the upper strata, people believe vaccinations adversely affect children. Once you sense that there is a possible harm of a medicine, you can’t help but stay away from it. I think we need more awareness so that we can make informed decisions.”

Mothers remain the central piece of this jigsaw puzzle, and convincing them of the benefits of immunisation seems to be one of the key factors. Dr Asad Ali, Associate Professor of Paediatric Infectious Diseases at the Aga Khan University, with a research focus on vaccine-preventable infectious diseases and malnutrition, says that the role of mothers in this regard is critically important. “Research shows that many a times, mothers are discouraged by the common side effect of short-time fever and local injection site discomfort after the vaccination of their baby. So they do not complete the series and also don’t get other children vaccinated. What they do not realise is that these transient side effects are a small price to pay for the critical protection their baby will get by receiving the full course of vaccines,” he says.

Dr. Ali adds that awareness needs to be raised among parents that vaccination is a right of their children. “Even if vaccinators are not coming to your house, parents must take their children to local governmental vaccination centers.”

Immunisation of children under the age of one-year against major vaccine-preventable diseases (tuberculosis, diphtheria, pertussis, tetanus, hepatitis B, Haemophilus influenza type B [Hib], poliomyelitis, and measles) is one of the most cost-effective means of reducing infant and child morbidity and mortality. The government of Pakistan initiated the Expanded Program on Immunization (EPI) three decades ago to save Pakistani children from these diseases. All vaccines in the RI schedule are provided free of cost in all public health facilities in Pakistan. Even then, the children are not given the coverage they deserve.

The Pakistan Demographic and Health Survey 2012-2013 sheds important light on some facts regarding the state of RI in Pakistan. Gender preference is seen even in RI. Boys are more likely than girls to be fully immunised — 56 per cent versus 52 per cent. Children’s birth order varies inversely with immunisation coverage — as birth order increases, immunisation coverage generally decreases. 64 per cent of first-born children have been fully immunised, in contrast to 39 per cent of children of birth order six and above.

“When I first became a mom, vaccination was a given; we diligently set reminders for our daughter’s appointments. It seemed as natural as buying diapers. Within the next three years, and with the transition from new mom to an experienced one, I began to read into everything from how the body has a natural mechanism for fighting fever to how to send more probiotics naturally to the gut. With the virals on the rise and doctors liberally prescribing steroids even for a blocked nose, I began to feel that there was too much of unnatural intervention,” says Nida Raza, a working mother of two and a resident of Karachi, who became lax regarding vaccination of her second child. “The anti-vaccination rhetoric on the internet and around didn’t help much and somehow my trust flew out of the window. I have been reading it and discussing it and yet I’m not convinced anymore; I’m confused about its benefits and authenticity.”

Urban-rural differences in immunisation coverage are clear. 66 per cent of children residing in urban areas are more likely to be fully immunised, compared to 48 per cent in rural areas, according to PDHS. There are wide differences in coverage by region. Islamabad has the highest percentage of children who are fully immunised (74 per cent), followed by Punjab (66 per cent) and Khyber-Pakhtunkhwa (53 per cent); immunisation coverage remains lowest in Sindh (29 per cent) and Balochistan (16 per cent), as per PDHS findings.

However, the latter two provinces are seeing a thrust in the efforts for reaching out to children who are not vaccinated. For Sindh, fresh research shows that the numbers of covered children are rising, thanks to efforts of EPI Sindh, yet much remains to be done, and unimmunised children continue to pose a challenge.

EPI Sindh’s Project Director Dr Agha Ashfaq, recently giving an overview of the programme to members of the media, said coverage of RI in Sindh has increased to 45 per cent. In view of the loss of lives of children because of Diarrhea, the Rotavirus vaccine is also being included in the RI in Sindh. Success in Sindh is being seen, for example no stock outs of vaccines were reported in 2015-16 in the province.

Vaccine Logistics Management Information System (VLMIS) is being set up in all districts of Sindh. Polio Eradication Initiative (PEI) and Sindh EPI are working in collaboration. Increased mapping of urban slums is being done. There is also newfound emphasis on the monitoring, evaluation and accountability framework. However, more emphasis is needed in raising awareness among parents, especially mothers, because eventually the decision to get one’s child vaccinated or not remains pre-dominantly with them.

Measles remains one of the key indicators of immunisation programmes in any country. Some 20 million infants missed their measles shots world over in 2015, and an estimated 134,000 children died from the disease. Half of the unvaccinated infants and 75 per cent of the measles deaths are in six countries; Pakistan is one of them. “The frequent outbreaks of measles in our country are a clear reminder that should convince parents about the need for vaccines for their children,” says Dr. Ali.

“Mothers in Tharparkar are very cooperative when it comes to their children’s health but they need to be convinced. We have not reached out enough to create awareness among the mothers,” says Dr. Aziz Kunbhar, former District Health Officer in Tharparkar.

Dr. Ali adds that awareness needs to be raised among parents that vaccination is a right of their children. “Even if vaccinators are not coming to your house, parents must take their children to local governmental vaccination centers.”

Burying prejudice in football one kick at a time

Published: July 1, 2015
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http://tribune.com.pk/story/912944/kicking-against-the-prejudice-that-hurts-womens-football-in-pakistan/
Mashal Hussain. PHOTO COURTESY: KARACHI UNITED FC

Mashal Hussain. PHOTO COURTESY: KARACHI UNITED FC

KARACHI: Ask her a simple question like ‘how old are you’ and you get a very poetic response from her. “Born in the sultry Karachi summer of ‘87, I’m approaching the cusp of 27 years now,” says Karachi United’s Mashal Hussain. This female athlete who has become an advocate for empowering women through sports can kick the ball hard, speak eloquently and keep her head in the right place.

Mashal recently got back after representing Pakistan at the Girl Power in Play symposium, held on June 18-19, 2015 in Ottawa, Canada, against the backdrop of the FIFA Women’s World Cup 2015. Creating ripples among female sportspersons of Pakistan, she spoke about how ‪Karachi United Football Club – Women’s Squad, have used the medium of sports to create positive social impact and in particular helped empower women.

Coming from what she calls ‘a fairly athletic and active family, always bustling around’, Mashal spent her primary years between Karachi and Toronto. Inclined towards sports from the beginning, she dabbled with many sports. “I stubbornly pushed our school to introduce basketball into the curriculum.”

PHOTO COURTESY: MASHAL HUSSAIN

However, her particular interest in football began in her junior year at McGill University where she briefly worked with the Men’s Varsity Team as a fitness assistant.

“The captain of the squad at the time sustained an injury and I was helping him recover through various drills and exercises. In doing so, I developed a liking for the game and began watching European leagues, learning the game and playing it.” A few months of coaching and the liking grew into a passion and she has been playing and coaching the sport ever since. She, accompanied by her younger sister, represent the same team now.

PHOTO COURTESY: KARACHI UNITED FC

Pushing boundaries as a woman

For Mashal and others like her who have pursued their passions on the road less travelled by females in Pakistan, the path is not always easy.

“Women’s football in Pakistan involves cultural frustrations, religious misconceptions, the issue of women’s rights, emancipation from a conservative tradition and a general changing of mind set of the local population,” says Mashal. The gender issue, according to her, is deep-rooted and is, globally, a feminist issue. In the context of Pakistan, Hussain admits that there is a gender bias regarding aspects such as funding, media promotion, government support, facilitation of infrastructure, grassroots development, and of course, awareness.

“Women who realise and follow their passion are rare in our society. And if that passion happens to be sports-related, we need to become the role models we want to look up to,” says Mashal.

When asked about the original and synthetic turf issue in the football world cup, which experts see as part of gender bias against female footballers, Mashal expressed satisfaction that at least the world has come to realise this.

“That is a positive step; not enough, though. While we’re fighting for media coverage and funding of grassroots development, the fact that uproar was created and acknowledged about this issue means that more people are paying attention.”

PHOTO COURTESY: KARACHI UNITED FC

Silver linings

Luckily for Mashal, her family has been supportive of her playing and forging a career in this field.

“I know how lucky I am and it is a personal goal of mine to influence today’s youth to become the kind of people my parents are.”

In addition, she has had a good experience since she began working at Karachi United.

“Most of our staff is male, but they never let the gender bias get in the way of football and my role as their superior. Outside the organisation, of course, no such utopia exists,” she says.

As one who has faced gender bias head on, Mashal does not only blame the men.

“Gender bias is also perpetuated and propagated by females in our country. So that is another barrier we strive to break.”

PHOTO COURTESY: KARACHI UNITED FC

Women must play

Women’s participation in sports is showing encouraging and important impacts on women’s development, of which Mashal is a strong proponent.

“Sport empowers women by instilling in them the confidence that they are often denied in countries such as our own. In sport, women are not only encouraged to be competitive, but they are also accepted for being aggressive and fierce with being labelled. It empowers women by giving them a sense of belonging,” says Mashal.

Mashal feels that including women would ensure the overall development of any sports industry that could potentially bolster the country’s economy and global standing and that the media will always sensationalize women’s sports.

“People shouldn’t be watching our players because of their aesthetic appeal or religious background. Instead, the success stories I consider truly inspirational are based on personal growth, economic empowerment, career development, societal contribution, impact and a personal sense of fulfilment.”

PHOTO COURTESY: KARACHI UNITED FC

State of women’s football in Pakistan

“Women’s football is abysmal in the country. That we are the only professional entity working towards grassroots development (girls between the ages of 3-16) should shed some light on why the country is ranked,” says a disgruntled Mashal.

The fact that an open trial for the national team has not been held in years sheds light on the plight of women’s football in the country. Mashal added that the local governing body is in cahoots and is struggling to understand that holding one tournament a year will not promote the sport at the grassroots or the competitive level.

“I cannot comment on discrimination, per se, but the state of affairs of Pakistan Football is laughable and sad at the same time.”

Aspiring female footballers look up to Mashal as a success story. When asked to comment on that, she replies that her story has barely begun.

“My story is in its initial chapters still. The plot has not thickened and the character development has only just begun. So, no, I do not consider myself a success story. However, I have had the pleasure of working with girls and women who are success stories already,” she says, and shares that some of the players that have come through the Karachi United (women’s) pipeline are proving to be real game changers for the organization, the team, and for Pakistan.

PHOTO COURTESY: KARACHI UNITED FC

Our voices must be heard

“It was empowering to be in the company of so many influential and driven individuals,” says Mashal, when asked about her recent experience at Ottawa.

Women Deliver, UNICEF, Right to Play, GAIN, and One Goal teamed up to host the Girl Power in Play symposium. The two-day event focused on the power of girls’ involvement in sport and gathered decision makers, sports stars, influencers, and girls and women involved in sport.

“I’ve met people whose stories resonate with me because I can appreciate their effort.”

Mashal had stumbled upon an open application for this event last year.

“I came across it while perusing how to get involved with the FIFA Women’s World Cup, for which opportunities were scarce. After I applied, they got back to me a few months later and we were good to go,” she says and commends Women Deliver for channelling everyone’s motivation and zeal into a productive and focused forum. Women Deliver is a global advocacy organization bringing together voices from around the world to call for action to improve the health and well-being of girls and women.

Mashal also said that the games have been great, though watching them from Pakistan poses problems due to relying on live streaming.

In the opinion of Mashal, the biggest obstacle to women’s participation and progress is opportunity.

“It will take a few generations, perhaps. I am so glad, however, to have been able to contribute towards this slow, but necessary revolution.”

World Pneumonia Day: Saving lives with cell phones

By Farahnaz Zahidi / Creative: Munira Abbas
Published: November 12, 2013

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Pneumonia claims an innocent child’s life every 30 seconds, making it the number one cause of childhood mortality. DESIGN: MUNIRA ABBAS

KARACHI: As she steps out of a small grocery store in Korangi, she is carrying her nine-month-old baby in one hand and bags of grocery worth Rs300 in the other. Her baby is pneumonia free and she is one of the lucky mothers who have more than one incentive to ensure her baby gets regular vaccinations at Karachi’s Indus Hospital.

In this part of Pakistan, cell phone technology is being put to good use, often ending up saving precious lives. Under the “Save Life – Zindigi Mehfooz Hai” programme by Interactive Research and Development (IRD), a system has been set up to not just treat children with pneumonia, but track them and their progress by using Radio Frequency Identification (RFID) technology.

In a country where reportedly some 92,000 children under-five die annually of pneumonia, which contributes to 18 % of the total child deaths in Pakistan, this is good news indeed. It is also encouraging that there is no refusal by parents of children when it comes to the pneumonia vaccine. “We have immunised 15,000 children in the last one year in Korangi alone, and not had a single instance of refusal,” says a proud Dr Subhash Chandir, director of vaccines program at IRD. The Pneumococcal conjugate vaccine (PCV) was introduced in Pakistan’s Extended Programme on Immunization in October 2012. “What fundamentally changed the game in Pakistan was not medical advancement but the fact that the price of vaccines came down,” says Dr Aamir Khan, IRD’s executive director , adding that a big part of the solution lies in social business models.

This use of RFID technology started with small water-proof, rugged looking bracelets given to children, which were scanned by assigned health practitioners to get a medical history of the child. Now, a small chip is placed within a sticker on the child’s vaccination card. Through that the child’s progress is tracked and reminder texts are sent. “Apnay phool jaisay bachay ki hifazat karain. Jamal Khan ka agla hifazati teeka aaj lagna hai (Protect your flower-like child, Jamal Khan’s next vaccine is due today).” Standardised texts like these serve as reminders.

To incentivise it further, a “lottery” is set-up whereby one in five mothers with children under the vaccination program may win grocery.

Pneumonia claims an innocent child’s life every 30 seconds, making it the number one cause of childhood mortality in the world. In the 2010 World Health Assembly, a resolution on the prevention and control of childhood pneumonia was passed. The UN MDG 4 states that childhood mortality should be reduced by two-thirds from 1990 to 2015. However, even now, globally an estimated 22 million infants are not fully immunised with routine vaccines.

The PCV vaccine costs around Rs1500 for Pakistan, but people can get their children vaccinated for free. The Hib (Haemophilus influenzae type b) vaccine was introduced in Pakistan even earlier.

Unicef shared with The Express Tribune that “The World Pneumonia Day serves as a call to action for parents, caregivers, and healthcare providers to ensure that infants are fully immunised against all vaccine-preventable diseases. Immunisation prevents between 2 and 3 million deaths globally every year by protecting against the nine deadly diseases of the childhood including pneumonia under 5 years of age.”

While the vaccines are there, they don’t seem to be reaching all Pakistani children who deserve to be vaccinated. “We have a grudge. We are pumping vaccines into a broken system. What needs to be corrected is vaccine delivery,” says Dr Khan. He feels routine immunisation needs to be strengthened, and it is wasteful to introduce new expensive vaccines into a system which is unable to deliver them.

Dr Chandir goes on to explain that the reasons include issues with the “Cold Chain”. Vaccines have to be stored at certain temperatures, but by the time they reach children, they may have lost their effectiveness. “EPI may have a network of vaccinators but often doesn’t have its people in strong positions at district levels. The human resource may not be enough, or is, may be, not being used effectively.”

“It is a crime because it is a right of these children to be protected against these diseases. Usually media stories focus on the vaccines — and not on the system. We need a better system in the country,” says Dr Khan.

Facts about the disease

• More than 99% of deaths in children due to pneumonia occur in the developing world, with half occurring in five countries – India, Nigeria, Democratic Republic of Congo, Pakistan and Ethiopia.

• Only 61% of children with pneumonia are reportedly taken to a qualified health practitioner in developing countries.

• Globally, pneumonia kills more children under five than any other illness.

• Infants not breastfed are 15 times more likely to die due to pneumonia than those who are.

• Using a clean cook stove results in a 50% reduction in the risk of a child contracting pneumonia.

Source: World Pneumonia Day website

Published in The Express Tribune, November 12th, 2013.

Preventable deaths: Pakistan continues to lose 60,000 babies annually

Published: May 9, 2013

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For Pakistan’s rural population, the major reason of infant mortality is the absence of functional health facilities, says Dr Ramesh Kumar. PHOTO: FARAHNAZ ZAHIDI

KARACHI: On a hot summer afternoon, a two-year-old sits in his paternal aunt’s lap in a remote village in Tharparkar district. He is too weak and malnourished to brush off the fly that sits on his face. The child would pass for a six-month-old. “His mother and newborn baby sister died three months ago, because the mother had prolonged labour, and with no transport, they died before they could be taken to a proper medical facility,” says the aunt. Some 25 women squatting on the floor start sharing their stories of loss. Every mother has a story to tell – stories of deaths that could have been easily prevented.

Pakistan’s human loss at the hands of neglect of public health is often trivialised when juxtaposed with causes that make headlines. But here’s a headline that should make us think: 60,000 Pakistani babies die every year on the first day of life. Pakistan has the highest first day mortality rate for babies in Asia, making it the most dangerous place in the region to be born, “Save the Children” says. The children’s aid agency launched its 14th annual State of the World’s Mothers report on May 7, revealing that 1-in-77 Pakistani babies die in their first day of life, making up 17 per cent of all under-five deaths in the country.

The report compares 176 countries around the globe, with regards to lives of mothers and their children. Pakistan ranked 139th on the best places to be a mother, based on factors such as mother’s health, education and economic status, as well as critical child indicators such as health and nutrition. It came in ahead of neighbours India and Afghanistan, but trailed behind Bangladesh, Nepal and Sri Lanka.

“The number of newborn deaths in Pakistan is unacceptably high. About 1-in-28 babies in Pakistan do not live past the first month of life, making Pakistan one of 10 countries accounting for nearly two-thirds of the three million newborn deaths that take place globally every year,” said David Skinner, country director for Save the Children in Pakistan. “Pakistan also has the highest number of stillborn babies in the region, at 1-in-23, many of which are preventable.”

“For Pakistan’s 70 per cent rural population, the major reason for the alarming rates of infant mortality is the absence of functional health facilities,” says Dr Ramesh Kumar, health coordinator of the Participatory Village Development Programme (PVDP), which works closely with local communities in Sindh on health and development. “Malnourished mothers are the reason why babies are born with low birth weight and often don’t survive,” added Dr Ramesh.

Low-cost solutions could dramatically reduce newborn mortality. Proper cord care and newborn/paediatric doses of antibiotics can be life-savers. A simple disinfectant like chlorhexidine, if used for cord cleansing, could prevent umbilical cord and belly button infections that can be fatal for newborns.

A simple, low cost corticosteroid injection given to women in preterm labour can save a child by helping mature the baby’s lungs. Yet, its availability is often a luxury for women for who even clean water and anti-bacterial soaps are a rarity.

Traditional birth attendants (TBAs) if trained and given proper support and supplies can save lives of thousands of mothers and babies. This is what PVDP does with its TBA training programme. “We give TBAs little ‘safe delivery kits’ that are life savers with simple yet indispensable things like gloves for the midwife, a plastic sheet to spread under the woman to avoid contact with soil, a sterile blade etc,” says Dr Ramesh.

However the most basic and underlying cause of newborn mortality remains gender inequality which translates into malnutrition of the mother. Physically, financially and socially stronger mothers would mean a better chance at life for babies.

Published in The Express Tribune, May 9th, 2013.

http://tribune.com.pk/story/546368/preventable-deaths-pakistan-continues-to-lose-60000-babies-annually/