Polio (Poliomyelitis)
Those who have lived the first 10 – 15 years of their lives in a Third World country are usually fully immune to polio through repeatedly swallowing small doses of the virus during childhood. In other words, nature feeds us ‘polio drops’ repeatedly for years without our being aware of it. Such natural immunity is robust and lifelong. It has the added benefit of arming the lining of our bowels with lasting immunity. Such individuals do not pass live viruses in their stools and are, therefore, no threat to the community. The lining of their immunized gut becomes a graveyard for any polioviruses that they swallow unknowingly. Only unvaccinated infants, young toddlers, and an odd kindergartner are susceptible to poliomyelitis if they encounter a large dose of the virus for the first time. That is why polio was originally called Infantile Paralysis.
Alaf Khan
The Daily Guardian (London, 5 April 2016) reported the murder of seventy polio workers in Pakistan’s Khyber Pakhtunkhwa Province alone between 2012 and 2015. Scores of more workers and their police escorts have been murdered since then. A government official supervising a polio drive in Mohmand District in early April 2019 was shot dead by the father of a child. The man lost his tribal temper when the official pressed him to present his child for the drops. A Police Sub-Inspector (Mr. Imran) was escorting the vaccinators in Domail near Bannu. He was shot dead by an anti-vaccine zealot. Two days later, on 24 April 2019, another police guard was murdered in Buner. Not a single person had died of polio in the whole country during the whole decade preceding these murders.
It is not to minimize the misery that polio can cause nor the importance of immunization against it; it is only to stress the deformed perspective. It is odd that the Extended Poly-Immunization (EPI) program was not resisted in the past, nor is it resisted now, except for the polio vaccine drops. Such a surge of violent opposition to the anti-polio drops is linked by many to a plan to locate and eliminate Osama Bin Laden rather than eliminate poliomyelitis.
The Pakistan government now irrationally requires outgoing air passengers to produce at departure a recent polio vaccination certificate. There is probably already a lucrative market for the sale of fake certificates. We have shown our skills in bogus business by awarding fake academic Degrees to our lawmakers, executives, and teachers. The Axact mega-scandal continues to echo around the globe. It is a multimillion-dollar business wholly dependent on the sale of fake degrees all over the world. Getting a fake polio certificate will cost peanuts or a phone call from an influential friend.
Bill and Melinda Gates run a countrywide campaign in Pakistan for polio eradication. Their Chief Executive for Pakistan once visited Peshawar. Prof. Nasiruddin Azam Khan, Prof. Ashfaq Ahmad, Prof. Rashid Iqbal, Prof. Zulfiqar Ahmad Bhutta, and I had a long discussion with him in the Pearl Continental Hotel. I asked the gentleman if he could elaborate on the reasons for his great concern about polio. His response was not very articulate. I then asked the four eminent clinicians if they could recall any person dying of polio in the preceding 15 years. None of them could. I asked them further if they knew about the large number of people who died of TB, tetanus, thalassemias, AIDS, rabies, and aerial firing. Their answer was a predictable Yes.
Tuberculosis (TB)
TB is a preventable as well as a treatable infection that is endemic in Pakistan. It kills and disables thousands every year causing great grief and socio-economic misery. You can count on at least one person coughing out T.B. germs in a cinema hall, an airport departure lounge, or a mosque during communal prayer.
We have a network of TB Associations in Pakistan. They don’t call themselves Anti-TB Associations. World TB Day has been celebrated on 24 March every year since 1995. The cost of these rituals and the dinners won’t be a small sum.
The Daily Mashriq (Peshawar, 6 April 2016) reported an incidence of 420,000 new cases of TB every year in Pakistan. The total number of TB sufferers at any one time in the country (i.e. its prevalence) would be in the millions.
Tuberculosis of the lungs was a global killer till about the end of World War II. I had, in my early life, known families who lost many members due to the so-called thinning disease (نرے مرض). Several members of a family in those days shared one large mud hut with clay walls and a thatched roof but no windows or ventilators. The prolonged daily contact spread the infection from one member to several others in succession or simultaneously. This had given rise to the notion that TB was a familial or hereditary disease (خاندانی مرض).
Countries once under British colonial rule were dotted with TB sanatoria as a valuable policy of the Raj. Well-ventilated rooms, fresh air, a nutritious diet, and a few heroic surgical procedures were the only treatment modalities. Many of our young doctors may not have even heard the words Thoracoplasty, AP (Artificial Pneumothorax), and PC (Phrenic Crush). These measures immobilized the infected lung just as a plaster cast immobilizes a broken bone. The imposed long rest encouraged natural healing and scarring of the affected lung. It is remarkable that members of the medical and nursing staff seldom, if ever, contracted the disease from their patients. The advent of streptomycin, isoniazid, ethambutol, pyrazinamide, and, finally, rifampicin made these procedures and sanatoria part of medical history.
BCG vaccination at birth and poly immunization in early life against several viral and bacterial infections ought to be made a condition for registration of birth, inclusion in NADRA Form B, school admission, driving license, National Identity Card, Passport, and Registration of marriage. False certification by health professionals, like the fake degrees of so many of us, shall remain a problem but its quantum will hopefully diminish gradually.
BCG vaccination on the upper arm fortunately leaves a scar that lasts for decades. A certificate of BCG vaccination without that scar is worthless. Doctors issuing such bogus certificates ought to be considered criminal offenders and dealt with accordingly. Reporting them to the Pakistan Medical and Dental Council is futile.
The World Health Organization (WHO), in its report for 2015, sounded the alarm about the ravages of TB due to the globally low expenditure on vaccination and treatment programs. Deaths from TB in 2014 numbered 1.8 million — 0.3 million more than in 2013. Statistics for 2015 estimated 10.4 million persons in the world with active TB. The organization pleaded for a minimum investment of 2.06 billion US dollars for TB research and treatment as against the then 0.7 billion dollars worldwide (WHO TB Report vide The News International, Pk, 13 October 2016).
AIDS (HIV)
AIDS is an acronym for Acquired Immune Deficiency Syndrome. The word acquired is added to distinguish this syndrome from the congenital lack of gamma globulin which is a recessive X-linked disorder carried by females and affecting only male offspring. In this respect it resembles hemophilia. HIV victims are born with a normally functioning immune system which is then knocked out by the AIDS virus, hence the word ‘acquired’.
The causative Human Immuno-deficiency Virus (HIV) is different from the viruses that cause polio, measles, smallpox, chickenpox, herpes, hepatitis, influenza, Covid-19, and the common cold. All these viruses attack the body directly like terrorists entering a building and shooting those inside. HIV, instead, only knocks out the guards at the gate and lets other terrorists do the shooting. HIV is like an enemy agent who disables your gatekeeper, opens the gate, and lets your other enemies do the rest unopposed. The human body is equipped with a huge and complex machinery that manufactures specifically designed bullets against each viral and bacterial enemy. This process is the body’s Immune Response. The bullet specifically designed against each virus or bacterium is an Antibody. The world we live in is teeming with viruses, bacteria, and other substances harmful to our bodies. We won’t survive long without these built-in immune defense systems. HIV switches off the factory that manufactures these specifically designed bullets against each invader. With the guards and the bullets gone, any burglar can now invade and loot the house unopposed.
HIV differs from other viruses and bacteria in its mode of transmission too. Malaria, plague, and typhus, for example, are transmitted from one person to the other by mosquitoes, fleas, and lice. These transmitters are technically called vectors. No vector is involved in the transmission of HIV. It is transferred from person to person through internal body fluids such as blood, lymph, semen, and vaginal secretions. HIV has not been found in the saliva, tears, sweat, or urine of infected individuals.
HIV infection hit the New World as a bombshell in the early 1980s. Some thought it was Nature’s slap on the face of humanity for its unbridled promiscuity and aberrant sexuality. Soon it knocked on our doors in the North West Frontier Province of Pakistan in the mid-1980s. Here are the stories of the first four victims of AIDS in our Frontier Province.
- A humble worker from Soor Gul village near Kohat was working in the UAE as a laborer. One day he vomited blood from a bleeding peptic ulcer. Multiple transfusions of imported blood saved his life in the short term but also loaded him with the AIDS virus. He returned home because of diarrhea, persistent fever, and much weight loss. His stay in the UAE, his bleeds, the blood transfusions, and now his persistent diarrhea and fever rang an alarm bell. The Aga Khan University laboratory reported his blood as strongly positive for HIV. His diarrhea and fever settled in a couple of weeks and was allowed home. We urged him to bring his wife for a blood test, but he never did. He was also asked to use a condom during sexual intercourse, but he probably never cared. A year later he appeared again at our Outpatient Department with a distressing crop of blisters on one side of his chest wall. This rash, called shingles, is not surprising in persons with a suppressed immune system as it is in AIDS. Some months later he appeared again and told us he was booked for surgery for his peptic ulcer. A Brigadier in the Combined Military Hospital (CMH), Kohat, had scheduled him for surgery in the ensuing week. It took me an hour of phoning different places to locate the surgeon and brief him on the risk involved.
- A young Afghan fighter clashed with the Soviets in the mid-1980s. His shoulder joint was crushed when a missile hit his bunker. One of his brothers had already been granted asylum in San Francisco, USA. He called his injured brother for treatment in San Francisco. The patient received several units of blood during the surgery. After his return to Pakistan, he came to us with a fever, diarrhea, and weight loss. With his history of surgery and blood transfusions, AIDS was now the first thing we considered. And that’s what it was. He and his family lived in an Afghan refugee camp in Bajaur Agency. We asked him emphatically to come back for a follow-up and to bring his wife too for a blood test. He didn’t return. My friend and co-tribesman, the late Rustam Shah Mohmand, was then the Afghan Refugee Commissioner. He located the man and sent a vehicle to bring him and his wife to us. Both spouses were now HIV-positive. He came only once again and was presented at our weekly clinical conference.
- A simple mother this time. She fell pregnant while staying with her husband in the UAE. She received several units of imported blood during her operative delivery. Fever, weight loss, and repeated lung infections made us suspect the dreaded cause. She too was strongly HIV-positive.
These were the first-ever known four cases of HIV infection in the NWFP (KP) of Pakistan.
From 4 to 16,000
Newspapers reported the following HIV figures by the end of 2014:
• Total HIV-Positive in NWFP: 16,000, only 1747 of them being registered.
• Peshawar: 228 known cases; Bannu: 110 cases. A total of 97,400 known cases in the whole country of whom only 9,865 received treatment.
The Daily Dawn (4 & 5 December 2014) reported a rough nationwide estimate of 97,000 to 125,000 cases. Ten thalassemic children were reported to have acquired HIV through blood transfusion. The same newspaper, on 5 December 2014, reported a total of 7,100 known HIV-positive persons in the province of Punjab alone. Out of these, 1,029 were mothers, 211 children, and 140 pregnant women.
The Daily Mashriq (Peshawar, 8 September 2019) reported a total of 9286 registered HIV victims in the Khyber Pakhtunkhwa Province. The actual total is believed to be much higher. Of the registered sufferers, 6706 are men, 2172 are women, 212 are young boys, and 146 are young girls.
This alarming spread of HIV infection does not seem to have perturbed the public or the health establishment as much as polio has done. HIV is largely spread through sexual intercourse, transfusion of infected blood, and sharing injection needles. Our sexual taboos and mock modesty about sex probably explain why we are so mute about our HIV prevalence.
The print and electronic media were flooded with reports of a huge outbreak of AIDS in the Larkana Division of Sindh and the Sargodha Division of Punjab in the first half of 2019. Thousands of adults and hundreds of children had been infected by a few quacks who had been injecting patients without changing the syringe and needle. The culprit in the Larkana village was himself an AIDS sufferer and was in prison awaiting trial at the time of the news report.
Thalassemias
These inherited blood diseases can be largely eradicated through a well-planned and rigorously implemented strategy over two to three generations. World Thalassemia Day is celebrated globally on 8th May every year with much fanfare. Appeals are made for voluntary blood donations. The medical fraternity, the NGOs, and our political establishment, however, have not evolved a policy for eradicating these killers.
Thalassemias were once endemic in the countries along the northern rim of the Mediterranean Sea. Genetic counseling based on a premarital blood test has conquered thalassemias in those lands. A person harboring a single thalassemia gene may have no symptoms. Such a person is a carrier. Two carriers — one male and one female — have a 25 percent chance of having an affected baby, 50 percent chance of having a healthy baby, and a 25 percent chance of producing a carrier. But human sperm and ova do not always obey arithmetic and statistics. Two carriers may produce any number of affected children; others may have only an odd affected offspring or none at all. The blood test for carrier state is simple and cheap. Mass awareness, genetic counseling, and blood tests before engagement are practicable options for eradicating these child killers. Unwed heterosexual partners should receive the same handling as those getting married. Cousin marriages need not be banned if both persons are non-carriers. The crucial point is to convince the couples of the need for the blood test before engagement.
Thalassemias are probably the second most common blood disease in Pakistan after iron-deficiency anemia. Stained films of red blood cells in thalassemia and iron-deficiency anemia look deceptively alike under the microscope. Unlike the iron-deficient red cells, the red cells in thalassemia are fragile, have a shorter lifespan, and are broken down prematurely in the spleen and liver. Other products of the breakdown of red blood cells are eliminated by the body but the iron part is retained. There is consequently an accumulation of large amounts of iron and a steady fall in the amount of oxygen-carrying hemoglobin. Each blood transfusion increases the iron load. The excess iron damages several vital organs, including the heart and the liver. The disease and the complications of its treatment greatly shorten the victim’s life.
The Balochistan province of Pakistan is home to the largest number of thalassemic patients in the country. Thousands need blood transfusions every few weeks. The blood supply for transfusion is becoming drastically short. Transfusions of unscreened blood have caused AIDS and viral hepatitis in unprecedented numbers of patients (BBC Urdu Service, 6 May 2019). Cousin marriages are admittedly common in Balochistan, but they are almost equally common in the neighboring tribal belt of K.P. province. And yet the incidence and prevalence of thalassemia’s are vastly different in the two regions.
Thalassemia’s vary in severity from the virtually unnoticeable to the one that grossly shortens life despite frequent transfusions. As noted earlier, the inheritance of one abnormal chromosome from each parent causes a severe form of the disease. Inheritance of only one abnormal factor from one parent makes you a carrier without being affected yourself. You are holding a loaded gun to the heads of your future offspring if you marry your normal-looking cousin who also happens to be a carrier like yourself.
A sustained awareness campaign by our community leaders, the clergy, the health ministries, the media, and the medical community can control, or even eliminate, the incidence of this preventable killer. We the physicians have regrettably failed to play our role in educating the public. We, the presumed Messiahs, ought not only to treat but also to prevent and teach.
Pakistan’s Daily Jang of 9 May 2017 reported a global incidence of 60 thousand new cases each year and a worldwide prevalence at any one time of 60 million patients. Thalassemia is one of those blights that make no distinction between the rich and the poor.
Tetanus (Lockjaw)
Tetanus, briefly mentioned earlier, merits some further elaboration. The dung of horses, donkeys, and domesticated cattle is a rich source of the germs that cause tetanus or lockjaw. Cattle dung is one of the most abundant materials in the rural environment in third-world countries. It used to be the sole soil fertilizer before the advent of urea, phosphates, and sulfate. Farmers working in the fields barefoot are at high risk of contracting tetanus through foot injuries. Women have been handling cattle dung for many purposes. Mixed with wheat straw and water, it is made into a dough for plastering the outer surfaces of mud walls and waterproofing the roofs. Such a dough (سپیاکے / آوپلے), when dried, is also used as firewood in domestic fireplaces and baking ovens (تند ور). Almost everything in a rural household is contaminated with tetanus bugs.
Ordinary knives and cotton rags are used to cut and tie the umbilical cord of the baby at birth. Senior rural women acting as midwives know not what infection means. Neonatal tetanus in the babies and postpartum tetanus in the mothers caused many deaths in the villages during my childhood. The services of Lady Health Visitors (LHVs) in the Basic Health Units (BHUs), obstetric services in public hospitals, and the mushrooming of private maternity homes have greatly reduced the incidence of neonatal tetanus in newborns and postpartum tetanus in mothers. There is, fortunately, increasing awareness and popularity of the relative safety of hospital delivery.
(To be Continued)
