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The disease that kills

Hepatitis C has become an epidemic in Pakistan and there is no end in sight since the governments neither have the will nor the wherewithal to control this disease

The disease that kills

The press is full of discussions about Ebola, dengue fever, polio and whatever other disease catches the fancy of our media and our ‘ruling class’ at any given time. I do not for a moment wish to denigrate the efforts to control any disease especially the ones I mention above. But there are other health problems that do not get adequate coverage. And no, I am not referring to a simple matter like waterborne diseases that could be controlled if clean water became available for people to drink.

Let me mention a particular condition that afflicts close to 12 million Pakistanis, more than 20000 new patients acquire this disease every year; a number greater than in any other country in the world, and more than 400 Pakistanis die from this disease every day. And in the Punjab alone there are more than six million people infected with the viruses causing this disease. What disease is this? Well dear readers if you have not figured it out yet, it is what we call Hepatitis C. (Statistics from Jang-Mera Shahr Lahore, October 28, 2014).

We in Pakistan have an ongoing epidemic of this disease and there is no end in sight since the governments neither have the will nor the wherewithal to control this problem. First let me address the question as to why this disease has become an epidemic in Pakistan. The reason is the way this disease is transmitted from one person to another and the way this disease behaves once it arrives in the human body.

The Hep C virus can only be transmitted if ‘blood’ from an infected patient comes in contact with and enters the body of an un-infected person. Now this would seem a bit difficult but there are three major ways that this can happen. First, and we include it primarily for the sake of ‘completion’, is during sexual activities. Second is through transfusion of infected blood into an uninfected person. Third is the use of injection ‘needles’ or ‘surgical instruments’ that were previously used on a patient infected with Hep C and are then used for injection or procedures on an uninfected patient without being sterilised.

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Statistics presented in a conference on Hep C held under the aegis of the Punjab Department of Health and as reported in the news item mentioned above suggest that the world over, on the average, one person receives one or two injections every year. However, in Pakistan, the average is between 13 and 14 injections every year and 70 percent of these injections are given using unsterilized needles or syringes.

In short, Pakistanis receive roughly a ‘billion’ injections every year of which 700 million are unsafe. And the number of possibly tainted blood transfusions, ‘roadside’ dentists and medical quacks using unsterilized instruments as well as drug addicts needles’ are above and beyond the ‘injections’ mentioned above.

Most of these ‘unsafe’ injections as well as unsterilized instruments are used by unlicensed and untrained individuals that pose as physicians or dentists and are often referred to as ‘quacks’. Estimates suggest that there are many times more of the quacks than there are legitimate healthcare providers in Pakistan. Clearly when adequate access to proper healthcare is not possible, people in need will approach whatever is available. And sadly for a majority of the poor patients and those in the rural areas it is these quacks that provide much of what goes for healthcare and the Hep C epidemic is just one result of this reality.

Now a bit about how the disease behaves once a person is infected. Hepatitis C and its less dangerous relative Hepatitis B are both transmitted in about the same way and behave in a similar manner except that Hep B is usually ‘self-limiting’ (most infected patients will recover completely) and that a vaccination is available to prevent infection by this virus.

The important thing though is that many patients with either of these infections might have slight symptoms originally that subside without any treatment. But many Hep C and some Hep B patients will remain infected but essentially free from any symptoms suggesting any sickness. However, after a period that might stretch into decades of a non-evident infection, these patients might develop serious liver problems requiring liver transplantation as the only viable treatment. And of course there is not a single active ‘liver transplantation’ centre in Pakistan.

The fact that hepatitis can lay hidden for years is one of the reasons for the persistence of this disease. Most infected patients probably don’t even know that they are infected. These infected persons can transmit these diseases to others even within their families (spouses-newborn children) and of course when they undergo minor surgical procedures (ear piercings or dental cleanings for example) and the instruments are reused on non-infected persons.

How then do we control this epidemic? First step of course is to try and identify people infected so that further transmission from them can be prevented. Since it is estimated that close to 12 million Pakistanis are infected, that makes it a monumental task to identify and test all of them. In the United States, for instance, all couples planning to get married are tested. Could that be done in Pakistan also? The next problem then is how to treat those that test positive and have an active infection.

Today Hepatitis C as well as Hepatitis B can be treated and the patients that become infected can literally be cured. But the treatments are extremely expensive by Pakistani standards and it is unlikely that the provincial government that is now responsible for healthcare can muster up the resources to treat the estimated six million Punjabis that are infected. Also a vast majority of those infected do not have the financial capability to pay for their own treatment. So of the 12 million Pakistanis including the six million or so Punjabis estimated to be infected, few if any will be identified and treated.

As far as prevention is concerned, obviously three areas need to be addressed. First is that of unlicensed medical providers or quacks. This can only be done if regular medical care that is affordable and accessible becomes available for all Pakistanis. And laws already on the books to prevent quacks from practicing need to be enforced. The second area is of appropriate oversight over blood banking services. And the third area is making sure that hospital waste that includes previously used needles and syringes is properly disposed so that these needles and syringes cannot be recovered and resold. And I am afraid to mention ‘safe sex’ for fear of being labelled un-Islamic.

Almost every family in Pakistan including the rich and the powerful has somebody suffering from Hepatitis. But the present government does not want to get involved since every measure to prevent and treat this disease requires resources that are beyond the capability of even the famously ‘efficient’ Punjab government. Building highways, flyways, underpasses and overpasses, and distributing computers to students are all a lot cheaper than saving these lives.

Syed Mansoor Hussain

syed mansoor hussain
The author has served as Professor and Chairman, Department of Cardiac Surgery, King Edward Medical University.

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