By Declan Walsh
A "humanitarian crisis of epic proportions" is unfolding in flood-hit areas of southern Pakistan where malnutrition rates rival those of African countries affected by famine, according to the United Nations.
In Sindh province, where some villages are still under water six months after the floods, almost one quarter of children under five are malnourished while 6% are severely underfed, a Floods Assessment Needs survey has found.
"I haven't seen malnutrition this bad since the worst of the famine in Ethiopia, Darfur and Chad. It's shockingly bad," said Karen Allen, deputy head of Unicef in Pakistan.
The survey reflects the continuing impact of the massive August floods, which affected 20 million people across an area the size of England, sweeping away 2.2m hectares of farmland.
The figures were alarming, Neva Khan, of Oxfam, said.
"Emergency aid right after the floods saved many lives, but, as these figures show, millions are at serious risk," she said.
Kristen Elsby, a Unicef official, called it a "humanitarian crisis of epic proportions".
But the figures highlight a broader truth: that Sindh, a ragged province where poor peasants toil under powerful landlords, has long had some of the worst poverty levels in South Asia.
"This sort of thing doesn't happen overnight. It indicates deep, slow-grinding poverty," said Dorothy Blane, of Concern.
The most recent nutrition survey across Pakistan in 2002 found a national malnutrition rate of 13.2%. The survey of 786 households, jointly carried out by the UN, aid agencies and the government, recorded global malnutrition rates of 23.1% in northern Sindh and 21.2% in the southern part of the province.
The survey was done in early November but Pakistan's government, reluctant to publish the figures, delayed their publication, according to several aid officials. Figures for southern Punjab, which was also badly hit, have yet to be finalised.
Sindh is Pakistan's third largest province and home to some of the country's deepest inequalities. Karachi is a bustling business hub of more than 16 million people. But in the countryside, feudal traditions are strong, illiteracy is rife and government services are often non-existent.
Health workers in refugee camps hosting flood victims from rural Sindh reported that some expectant mothers had never seen a doctor.
Across Pakistan, most of the 14 million people who fled their homes in August are rebuilding their lives. According to the UNHCR some 166,000 people are living in 240 camps and roadside settlements, down from 3.3 million in October.
Much western aid has been pumped into a scheme to give flood victims direct financial aid, starting with a payment of £150. Some aid workers say it is prone to corruption.
The UK donated £114m which funded shelter for 1.3 million people and clean water for 2.5 million.
But more money is urgently needed. A UN appeal for $2bn to help people survive until this summer has only 56% of the funding.
Before the floods the western aid effort in Pakistan focused on the north-west, where an earthquake struck in 2005 and military operations against the Taliban have displaced millions.
After the floods, aid workers admit to being caught offguard by the problem in Sindh. "It was a real wake-up call," said one.
Some villages in northern Sindh remain under water, and where the water has cleared, irrigation systems lie destroyed, raising concerns for the next harvest this summer.
And some things will take more than food or shelter to solve. A majority of children in flood-affected areas suffer from anxiety, depression and phobias, according to a study by Save the Children.
Of the children surveyed, 70% expressed fear of "people, water, open places and darkness", it found.