June 11, 2019
Naseem Salahuddin, an infectious disease specialist, looks at the bigger picture in Pakistan.
THE Larkana HIV outbreak has opened up a can of worms throughout the length and breadth of Pakistan, exposing our feeble healthcare system — of which infectious diseases (IDs) comes into sharp focus. I do not recommend the following exposé be read by the faint-hearted, nor by those in positions of decision-making who have only observed health inequities from the comfort of their offices. It might hurt their sensibilities.
A snapshot of a day in the ID department of the Indus Hospital, Karachi, will give the reader stomach-churning insights into the lives of the poor and sick.
In the TB clinic, over 200 patients are waiting to be diagnosed or receive their free medicines, a third of whom have drug-resistant TB. One is a woman with both lungs destroyed by the most drug-resistant form of TB, pregnant for the ninth time, sharing a two-room shanty with 35 others, six of whom have had TB.
Another, a garment factory worker with syphilis, brings his two wives for checkups, boasting of his 20 children. The mother of 13 of his children has acquired his syphilis, while the mother of his seven children mercifully tests negative. A 53-year-old man is wheeled into the emergency room, vomiting blood due to liver cirrhosis from chronic hepatitis.
A phone call from JPMC informs me of their fifth case of rabies in three months brought from interior Sindh, where no vaccine or rabies immunoglobulin (RIG) is available — the child’s death is inevitable. Our rabies prevention clinic informs me of 15 people bitten by a single rabid dog that has inflicted wounds on the face, neck, trunk and limbs. We can expect an onslaught of infectious disease outbreaks.
In the ward are patients with life-threatening AIDS, drug-resistant typhoid, fragile young women with bellies full of tuberculous fluid. A microbiologist messages from her phone, deriding a private laboratory that habitually reports misleading results which cost the patient precious money and weeks of futile medicines. Another colleague from Swabi shares his caseload of Congo hemorrhagic fever.
The Indus Hospital is but a microcosm of the larger picture: vastly overcrowded government hospitals where young doctors work fast and furiously to alleviate the sufferings of the wretched. The sick arrive in droves from distant villages, parking themselves from the early hours on broken sidewalks, hoping to be attended to.
Supplies of anti-rabies biologicals are rapidly depleting, as are other useful vaccines. We dread the day we see upsurges in deaths from the world’s most horrific diseases. Tongues will click and hands will be wrung, as more deaths hit the headlines. Cases of drug-resistant typhoid originating from sewage-contaminated water pipes escalate daily. Come summer, mosquito-borne malaria, dengue and chikungunya will fill outpatients and hospital wards, rendering absenteeism in schools and workplaces. We are desperately hoping that the Zika virus never enters our skies, which, given our high fertility rate, will cause tens of thousands of malformed newborns.
Having placed this brief but sordid reality sketch before the reader, it is evident that most IDs are a result of poor governance.
Sewage-contaminated water is replete with bacteria and viruses that cause diseases like hepatitis A and E, cholera, typhoid and dysenteries. When a carrier’s infection-laden excrement mixes with the city’s water supply, the consumer inherits these infections. It is not practicable for a large household to boil cauldrons of water daily, and neither can they purchase expensive bottled water. Water supply to citizens should be properly chlorinated at source, and rusted and broken pipes replaced and separated from sewage pipelines.
The mounds of garbage attract flies and mosquitoes, while cats, rats and dogs feed off trash. Every household, community and municipality must vociferously promote and publicise personal and environmental hygiene. Organised trash collection and disposal is the only solution. More than half of public health diseases will disappear by improving sanitation.
The PMDC must make it mandatory to teach holistic healthcare. Practitioners with medical degrees from more than 150 dubious colleges are not necessarily proficient in healthcare management. Many are responsible for perpetuating IDs through syringes and bad prescriptions. The subjects of diagnosis, treatment and prevention of common IDs in Pakistan, as well as medical ethics, are woefully absent from the curriculum, and should be introduced at basic levels.
Finally, no amount of health regulating will succeed if the population continues to proliferate at the present annual rate of 2.5 per cent. Overcrowding and sharing of scarce resources negate attempts to create a healthy population. Population control must be placed highest on the list of the country’s priorities.
It is never too late. Proactivity from those in power can still prevent massive ID calamities. If ignored, we will be doomed.