Baltistan, a land of rocky mountains, glaciers, streams and apricot gardens, lies on the upper reaches of the river Indus in the Northern Areas of Pakistan between the high mountain ranges of the Karakorums bordering on Chinese Sinkiang in the north and the western end of the Himalayas, and Kashmir in the south.At an altitude rising from 6,000 feet near Gilgit to the summits of the Nanga Parbat at 8,126 m in the west and the world's second highest peak, the K-2 at 28,253 feet in the north, it covers an area of 26,000 square kilometres. It has a population of around 300,000, about 50,000 having settled or working downcountry or abroad.
Because the country was off the ancient trade routes to China, access and passage to it was difficult, till the opening of air-traffic and road traffic via an extension of the Karakorum Highway, both as late as 1982. The winters are long and hard (a record -35° C in Jan/Feb '95). The main crops cultivated are barley, maize and buckwheat, some vegetables and a variety of fruit. Steep rocky slopes and sparse vegetation offer limited possibilities for cattle rearing. Goats, some sheep, a little poultry, cows and dzos, a cross breed of cow and yak, the latter living only on high altitudes, are the only meagre sources for meat, milk, cheese and butter.
The Baltis are mostly small in stature and tough survivors, their outlook
being conditioned by a hard fight for existence in an overpowering high altitude
environment. They were Buddhists until their conversion to Isalam in the
15th century, belonging to the Shia sect seeking religious guidance from
modern day Iran. The people speak mostly Balti, an archaic form of Tibeti,
and in a few areas Shina, a Dardic language, both languages with no script.
The narrative art has therefore a strong tradition in their culture, the
Kaisar saga or epos being the most prominent example of narrated literature.
In the schools only Urdu and English are taught, which are also used in the
offices and courts. Liberation from the oppressive Kashmir Dogra rule in
1948, the abolition of the local principalities in 1972, and limited natural
resources have prevented social differences from becoming too pronounced
among them.
The project
We began our work in 1989 in the small mountain town of Skardu, at that time
the district capital of Baltistan, which has now two Districts, Skardu in
the west and Ghanche with Khaplu as district headquarter in the east. We
noticed that there were hardly any medical services for women available,
and especially no gynaecologist for the entire area. Family planning kowledge
and services were practically non-existant and birth-deliveries were cared
for by relatives or untrained dais; accordingly fertility rates as well as
relatd mortality were exceptionally high among women. Girls get married around
the age of 15 and women have an average of over 10 pregnancies and raise
about 8 surviving children. The record among our patients stands at twentysix
deliveries with 18 children alive. They love to have large families and consider
every addition an added labour force and income generator to the family,
but since family planning is promoted in Iran following the fatwa of Imam
Khomeini, there is hardly any opposition to it on religious grounds, and
where services become available it is practised after the sixth child by
women, less by men. This requires not only availability of services, but
quality medical after-care as near to the patients as possible, to advise
and treat in case of the usual side-effects and complications. Women share
in addition to their childbearing and rearing the hard physical labour in
the fields and around the house, despite their malnutrition, and accordingly
liefe expectancy among women is much lower than with men, leading to a sex
ratio of 115 men and 100 women according to the 1981 Census. The literacy
rate among women was reported to be 2.1 %. No newer figures are available,
but that rate may have declined due to a population growth higher than that
of increased female education.
Rahman Clinic/Mother and Child Health Centre
To begin with, the clinic was housed in a shop in the main bazar. An increasing work load forced us to shift three times to larger premises. Initially medical doctors were not always available; now there are a lady gynaecologist, midwives and a dispenser-cum-medical technician, and its facilities include a gynae-theatre-cum-labour-room, a ward with ten beds, a dispensary with lab-facilities, X-ray and ultrasound with generator, the doctors' outpatient examination-room. It has a class-room for the training of para-medicals, including literacy, and 20 female community healthworkers for a period upto three years, in midwifery, family planning, first-aid, infant healthcare, hygiene and nutrition, working in the clinic, in medical field camps and in the community they live in. Fifteen of them have now opened Community Health Centres in their neighbourhood in Skardu or villages around with the help and support of the community and our Foundation. They examine patients, make home-visits for purposes of health-education including family planning counselling and promotion of immunization and ante-natal tetanus injections, ORS and iodized salt. They also provide first-aid and carry out home deliveries, charging lower than the clinic fees for their services, so as to encourage the utilization of the services. To reduce the fast rising cost of medication an R&D project for the use of traditional and herbal medicine is under preparation.
The clinic examines on average 30 patients per day and another 100 at medical
field camps carried out periodically in surrounding villages. The clinic
participates in the annual polio-vaccination campaigns. Income from patient
fees for consultation, examination and treatment does cover over by now 20
% of the recurring cost, which does not include the training and capital
costs of the programme. The acquisition of an anaesthetic machine permits
us now to offer selctive gynae surgery, which most of women beyond the age
of 35 do require here.
School Health Programme
In 1994 we introduced a school health programme, with a paedriatician gradually
visiting all the schools in Skardu District, entering into agreements with
the schools and the community, for general check-up of all school children,
including immunization and advice to parents for treatment or further diagnosis,
where necessary e.g. X-ray in case of suspected T.B; routine anti-worm treatment
is given, in addition to health-education of children, teachers and parents,
and first-aid training to teachers, older students and community healthworkers.
The doctors survey the schools's environment health standard, e.g. crowding
of rooms, seating, light, temperature, ventilation, cleanliness, sanitation,
drinking water, sports facilities, school ground, traffic hazards, etc. To
generate income for the school welfare fund, environmental improvement of
the school and environment education, trees are bring planted in the school
compound and maintainded by the children. In some cases even tree nurseries
are maintained for subsequent plantation on community land, for sale of trees
and wood in subsequent years. First-aid boxes are acquired, lessons on local
wildlife and environment protection by one of our team mates and on traffic
behaviour by the local police are being given, and competitions are being
arranged, e.g. speech contests, essay and drawing competetions etc. on the
topics of health and environment. Walks to highlight these issues for the
general public are being organized. Similarly our doctors and environment
experts give talks over the local radio station on these topics. Recently
a photo-exhibition on Italian mountaineering expeditions to the K-2 and efforts
in cleaning up its environment was organized in the District Council Hall
and school; classes were invited to visit it. Donations are being collected,
to make school benches at Skardu, to be supplied to the schools with little
or no furniture, to prevent chronic illness among school children forced
to squat on ice-cold class-room-floors. To highlight the problem, provide
skill-training to the elder school-children and install a pride of self-help
and labour by their own hands, they are involved in assembling and giving
the finishing touches to the benches under the supervision of their technical
training teachers.
Home and Environment Improvement Programme
Besides the environment education and improvement programme in the schools,
a similar one has been started for the improvement in and around people's
homes, as no healthcare will be able to succeed, unless prevention through
hygienic living conditions accompanies it. Initially the increasing cost
of fuel for cooking and heating, deforestation due to consumption of firewood,
as well as creating more hygienic living conditions, led us to experiment
with the introduction of fuel-wood saving stoves, to be produced locally
and marketed by the female community healthworkers. Making drinking water
safe and temperate water available for washing, is the next step, with
investigations into the improvement of housing design and building material
to follow.
Prevalent health problems among women and children
As everywhere in the country infectious diseases are most common, especially intestinal parasites among children. Similarly infections of the respiratory tract. Defective nutrition, poor hygiene and arduous work possibly explain the widespread nature of tuberculosis. Also bronchial asthma is often to be found. Diseases affecting mobility are probably the most frequently encountered, possibly because of the cold winters with badly heated accomodation. Findings from 102 patients examined in April 1992 and from 1,174 from mid-June until the end of August 1994 at our clinic at Skardu showed the following symptoms (excluding vaccination, ante-natals and family planning patients):
Life expectancy is low, around 50 years. Official statistics are not sufficiently reliable. Malnutrition among women is prevalent, due to too many pregnancies in quick succession. They lack high quality protein, iron, iodine and calcium. With the help of a procedure recently developed at Heidelberg University we were able to evaluate the haemoglobin and vitamin B2 (riboflavin) from a drop of blood taken from the finger-tip of 90 patients. In the case of half the patients the haemoglobin was under 11 g/d1, the standard figure for people living at high altitudes below which deficiency is diagnosed, and in the case of two pregnant women and one child it was only 5g/d1. Riboflavin is one measure of the quality of nutrition. It is essential for the development of embryos and of children and is contained above all in animal products. Our measurement showed a reduction of riboflavin of a factor of 4 compared with European levels. Whenever made available by the World Food Programme we therefore provide nutritional support to malnourished women patients, and after a long struggle we were able to acquire iodized salt, which we promote through our clinic, field camps, school health programme and community health centres.
|
|
|
| Unspecified weakness/pain/fever (also headache)
Respiratory tract, coughing, sputum, breathing difficulties (also tonsillits, otitis media) Abdomen: vomiting, diarrhoea, stomache ache, swelling of the liver and spleen, other disorders Movement of limbs: pain, swelling and abnormalities of the joints, traumas Uro-genital pain, burning sensation when urinating, abnormalities in menstruation Skin/Hair: alos parasites, otitis external Visible malnutrition incl. anemia |
|
|
| Total | 102 100 | 1174 100 |