The health and social needs of children in impoverished areas
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Dr Manzoor Ahmed Butt
Contributing Editor and Photographer for MEJFM
Family Physician, Researcher & Trainer
Chairman of Board, WorldCME-Australia
Member of Executive Board of Child Watch, Australia
Chief Editor of Child Watch section, Middle East Journal of Family Medicine
“Global Family Doctor Award” for August 2003 by WONCA-online, Australia.
Member of Middle East Primary Health Care Research Network
Member of International Federation of Primary Care Research Networks
Official Press reporter & Photographer of Medi + World, Australia
Rawalpindi, Pakistan,

Address correspondence to:
Dr Manzoor Ahmed Butt, Email: manzor60@yahoo.com
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Despite living in close vicinity to Islamabad, the children of Shamsabad face many health problems. The under-5 morbidity and mortality is very high in this community.  The main reasons for this are:

1. Inadequate health care facilities for this age group
2. Inability of parents to access available health care facilities, due to poverty and ignorance
3. Inavailability of school health services in the community.

Impairment of visual acuity, chronic ear discharge, chronic diarrhoea, recurrent chest infections and malnutrition are very common in impoverished  communities like ours. The Child Health sector of Shamsabad Mother Child Health Program especially concentrates on health of deprived children in orphanages and community schools, both regular and those meant for Special children.

Our focus of this article is on preventive aspects of Child Health. Our health workers have dedicated their efforts towards improving the personal hygiene and prevention of blindness, deafness, and malnutrition in the region.

About 75% of the blindness occurring in developing countries is avoidable, i.e. it is either treatable or preventable [1, 2]. According to the population-based survey 1987-1990, conducted by the Ministry of Health of Pakistan and the World Health Organization (WHO), a prevalence of blindness of 1.78% was found in Pakistan. The major causes of blindness are cataract, corneal opacities, uncorrected refractive errors and glaucoma. [3].

Inadequate intake of protein, calories, iron, and other nutrients make up the different types of malnutrition. As many as 800 million persons worldwide are affected by malnutrition. More than half the childhood deaths in developing countries are related to malnutrition [4]. If the body does not receive the energy it needs in the form of food, weight loss will occur. Children with malnutrition have inadequate fat stores and very little muscle. Their bones are prominent and they often have disproportionately large abdomens. Brain development can be impaired, and these children have a high incidence of disease because their bodies cannot fight infection. Malnutrition contributes to the high death rate among children in developing countries. [4].  The body requires micronutrients from diet because the body does not make all the products it needs for optimum function. Micronutrients include vitamins A, B, and C, folate, zinc, calcium, iodine, and iron. The 3 major micronutrient deficiencies in the developing world are iron (anaemia), iodine (deficiency can cause goiter and can lead to death or mental retardation for a developing fetus), and vitamin A. Vitamin A deficiency is a serious worldwide medical problem because it is the leading cause of preventable blindness in children. [4].

Worldwide, iron deficiency is the most common form of malnutrition. As many as 4 billion individuals may lack enough iron in their diet. Malaria and parasitic infections are common contributing causes. Iron deficiency causes anaemia (low red blood cell count). Anaemia causes fatigue, may cause heart failure in severe cases, and may also affect brain function. Preventing iron deficiency requires an adequate diet including iron-rich foods such as leafy green vegetables, beans, and red meats. [4].

To summarize, the following are the common Medical Problems in our community:

• Anaemia
• Poor Oral Health
• Slow Development
• Eczema and Scabies
• Hearing deficiencies
• Visual deficiencies
• Iodine Deficiency
• Parasitic and Bacterial Intestinal Infections
• Malnutrition, Growth Failure and Rickets
• Asthma
• Tuberculosis
• Inadequate vaccine facilities 

Many of the blind girls have been unable to get even primary education in the wake of non-existence of special educational institutions for them, interviews with blind girls in Peshawar revealed. [5] The problem is exacerbated by the fact that those wanting to get education have to leave home and face a number of problems.

The girls are provided education only up to primary level and after completing five years they have to either leave their studies incomplete or go to a middle school in Islamabad for further studies. [5]. The examination system does  not provide much relief to the blind candidates. Blind candidates are  supposed to attempt the same paper and are  given only 45 minutes additional time along with the three hours to solve a question paper. The blind candidates who appear with the normal candidates in examination are  provided with a one class junior writer. [5].
 
Many parents of the blind girls are already afraid to send their daughters to the far off educational institutes as the biggest problem is to pick up and drop them. Many districts have institutes for the blind boys but the parents could not send their blind daughters to the mixed environment. Many blind girls remain deprived of the enlightenment due to the lack of facilities for special persons. [5]

Our health workers are working to solve health problems of blind girls in a school which is situated in Shamsabad. [6] We have determined that in addition to medical problems mentioned above, they have difficulties in maintaining personal hygiene. The most important in this regard is care during menses. They have a free treatment facility at Rawalpindi General Hospital but they cannot go there, especially at night, because no body is free enough to take them to that hospital.

Our Strategy for these girls

1. We are already providing them treatment at low cost.
2. We have started health education especially in personal hygiene, care and protection during menses plus oral care. Our team visits them regularly to provide them this education, training and essentials of personal life like soap, toothbrush, toothpaste, shampoos, detergents, accessories used during menses.
3. To help these girls, we have to have an exact understanding of their usual habits. Towards, this end, we did various surveys.
4. We have established a small first aid dispensary in this school to cater emergency first aid medicines, for example, analgesics, anti-emetics, anti-diarrhoeals, etc.

To make this dispensary useful and safe, we have selected their Hostel warden for training as a Health Worker. Ms. Fauzia Khanum, who is also their senior school teacher, daily attended our clinic at evening [her free time from school] for 6-weeks to learn the basics.

Community Based School Health Service is our main Strategy to address these problems.  We are striving;

• To train health workers in school health services
• To train health workers in record keeping and reporting
• To identify preventable diseases in under-5 children
• To identify communicable diseases in under-5 children
• To identify anaemic and grossly malnourished under-5 children
• To treat anaemic and grossly malnourished under-5 children from our clinic’s own resources
• To inform parents of suffering children, about early management of diagnosed problems.
• To establish a referral to experts system for the sufferers
• To assess and record general health status of under-5 children of the community

The trained health workers have been divided into two groups. A smaller group deals with all under-5 children coming to our clinic for any reason. A bigger group visits all schools of Shamsabad.

The health workers examine and record the general physical examination and systemic examination with special attention to common diseases of this age group. They screen out the sufferers and arrange their check-up with a GP. The children who can be managed in the clinic are given full assistance and guidance. The very poor are given free treatment and those who can afford are given treatmentat small cosr. The difficult to treat cases are referred to experts for investigation and care.

1. Training of Blind girls in oral care. [6]
2. Training of Blind girls in Special care during menses. [6]
3. Screenng of eye problems, with special attention to Visual Acuity, night blindness, problems of cornea, conjunctiva, and sclera [7]
4. Screening of ear problems, with special attention to ear drums, difficulty in hearing [7]
5. Screening of malnourished children, with special attention to growth retardation, chronic diarrhoea, repeated chest infections, anaemia, Rickets [7]

Activity executed by Project Team Leader - Mrs. Rahila Manzoor

Team Members: Ms. Sajida [Senior Community Volunteer & School Teacher], Mrs.Afshan Munir [Junior Community Volunteer & House-Wife], Mr. Mumtaz Bhatti [Senior Communty Health Worker as Support Person]

Personal Hygiene Survey - Oral Care

Total girls in the school hostel ------ 75                     
Total girls present during visit-------61
Total girls interviewed: ------ 61

Question 1:
What  methods do to use for cleaning your teeth?

Question 2:
If you brush your teeth, what materials do you to use? [43 out of 61]

Question 3:
Whatever the method & material, how many times do you clean your teeth?

Question 4:
When do you clean your teeth?

Question 5:
Do you have bleeding from your teeth?

Question 6:
Do you have bad odour from your mouth?

Question 7:
Did you understand the information that we have conveyed to you?

Question 8:
Are you now convinced that we should regularly brush our teeth with an adequate toothpaste at least twice a day, once after breakfast and secondly before going to bed at night?

Activity - Provide toothpaste, brushes

2. Menstruation & Feminine Care

Total girls in the school hostel ------ 75
Total girls present during the visit-----61
Total girls who have periods-------20 [others are of younger age group]
Total girls interviewed: ------ 20

Question 1:
Do you bathe during menses?

Question 2:
What do you think about menses - is it a natural process or a disease?

Question 3:
Should a girl/woman continue normal activities & games during menses?

Question 4:
What material do you use during menses?

Question 5:
Did you understand the information that we have conveyed to you?

Question 6:
Are you now convinced that girls/women should regularly bathe and continue work and games during menses because menses is a natural process and not any disease?

Activity: Teaching the girls how to do feminine care - provide soap, cotton, underwear and cloth for making pads
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Screening of eye problems:
- with special attention to Visual Acuity, night blindness, problems of cornea, conjunctiva, and sclera.

Screening of ear problems:
- with special attention to discharge, ear drums and difficulty in hearing.

Screening of malnourished children:
- with special attention to growth retardation, chronic diarrhoea, repeated chest infections, anaemia and rickets.

Health workers are questioning the girls about their various problems

Mrs. Rahila Manzoor is training teachers of blind school on how to make sanitary pads and about personal hygiene. These teachers in turn train the blind girls in this knowledge and skills.

1. Kupfer C. Worldwide prevention of blindness. American journal of ophthalmology, 1983, 96:543-5.
   
2. Methods of assessment of avoidable blindness. Geneva, World Health Organization, 1980:1-42 (WHO Offset Publication No. 54).
   
3. Memon MS. Prevalence and causes of blindness in Pakistan. Journal of the Pakistan Medical Association, 1992, 42:196-8.
   
4. Journal of American Medical Association, Vol. 292 No. 5, August 4, 2004, http://jama.ama-assn.org/cgi/content/full/292/5/648
   
5. Blind girl students facing problems [Peshawar] By Sadia Qasim Shah , Daily Dawn, Sunday 19-09-2004, http://www.dawn.com/2004/09/19/local17.htm
   
6. Government School for Blind Girls, Shamsabad, Rawalpindi.
   
7. Leading Public School, Awan Colony, Shamsabad, Rawalpindi - a school for low income group.

The Rawalpindi home for blind girls is our first philanthropic project and next issue we will outline our goals, and how we hope to achieve them. We have received a donation to assist and we will provide a full breakdown on the use of any donated monies for this or subsequent projects

Our second project will look at the many needs of Iraqi children and we welcome your advice and articles on what the greatest needs are and how you feel they can be solved.

Lesley Pocock - Publisher
lesleypocock@mediworld.com.au