How hepatits C has reached alarming levels in Punjab

Zahoor Ahmed fell ill around four years ago. Doctors at a private hospital examined him and found that hepatitis C had damaged his liver but treatment was still possible. His brother and nephews took him everywhere to explore that possibility – to public hospitals, to private ones, to Lahore, to Faisalabad – but his condition continued to worsen instead of improve.

“One day his skin turned yellow and he started crying for help because he was in pain,” says his daughter Aqsa, a third-year student at a government college in Hafizabad, a small city in central Punjab. He was immediately taken to Faisalabad’s Allied Hospital, a large government-run facility, where the doctors said he had passed the stage where his liver could be brought back to health with medicine alone. In the summer of 2015, his family took him to the Doctors Hospital and Medical Center, an expensive private diagnostic and treatment centre in Lahore. He stayed there for almost two months but his condition did not get better.

Some doctors, meanwhile, said Ahmed urgently needed a liver transplant and suggested he be taken to New Delhi’s Apollo Hospital. The transplant there required close to 10 million rupees. His family, who owns and cultivates farmland in his native village of Kot Sarwar, arranged the money and sent him to India towards the end of 2015. Aqsa went with him.

The doctors told her that she needed to donate a part of her own liver so that it could be transplanted to her father’s body. She immediately agreed, hoping that this would save her father’s life. The transplant did take place but Ahmed did not survive. He passed away in January 2016, leaving behind Aqsa and a five-year-old son. Their mother had died earlier, so the two siblings now live with their paternal uncle.

Many other well-off residents of Kot Sarwar have also had liver transplants from India in recent years. All except one of them have died.

Kot Sarwar is not a poor backwater. Its canal-irrigated lands are fertile and its landowners prosperous. Many local residents are highly educated and have government jobs in various fields ranging from education to the police. Others run businesses within the village – including well-stocked grocery stores and a petrol station – and a number of them are employed at a nearby rest area along the Lahore-Islamabad Motorway.

The village is well connected through an extensive road network — to Hafizabad, which is about 25 kilometres to the north; to Lahore, about 115 kilometres to the east and Faisalabad, about 81 kilometres to the south. Roads are good and it takes less than two hours to reach each of these cities from Kot Sarwar.

The village also has a government-run basic health unit but hardly anyone goes there for treatment. Its incharge, a lady doctor, visits only occasionally from her residence in Lahore. A paramedic lady health visitor and a clerk are available regularly but they cannot examine patients or prescribe medicine.

Saira Afzal Tarar, who had been federal health minister since 2013, represents the same district in the National Assembly of which Kot Sarwar is a part. Yet, untrained, uncertified medical practitioners, locally known as doctors, openly operate here and awareness of health hazards is dangerously lacking. Even the educated residents of Kot Sarwar get their haircuts and shaves from hereditary barbers who have been working for landowning families for centuries and use the same unsterilised scissors and razors for every customer.

Consequently, hepatitis C has reached the level of an epidemic here. The extent of the disease’s prevalence first became known in 2017 when a Lahore-based medic set up a medical camp in a nearby village with help from a pharmaceutical company. Out of the 214 people tested at the camp, 112 were found to be suffering from hepatitis C and four from hepatitis B. A letter published in the daily Dawn’s December 24, 2017 edition pointed out that scores of patients from the area had registered themselves with a hepatitis control programme run by the Punjab Health Department “but no medicine was provided to them”.

The writer of the letter, a resident of Hafizabad, added: “If this were to happen in any other country, a medical emergency would have been imposed.”

Abdul Ghafoor is the portrait of a defeated man. His uncombed hair and dishevelled clothes give away his grief, even from a distance. Sitting on a dark red carpet under a bright yellow canopy covering part of an open, dusty street on an April day this year, he looks stricken. Shameem Akhtar, his wife of more than 20 years, passed away two days ago. She was only 44.

Ghafoor does not remember when exactly Shameem was diagnosed with hepatitis C or when the disease began damaging her liver. “She started falling sick around four years ago. She often had headaches and stomachaches and threw up routinely,” he says. “We tried every remedy at home and also took her to a number of doctors but her condition never improved.”

These “doctors” are all quacks, operating in his village as well as in a commercial area at a bus stop two kilometres away.

When her health deteriorated further, Ghafoor took Shameem to the district headquarters hospital in Vehari city, about 20 kilometres from his village, 155-WB Thengi. “Doctors there screened her blood and told us that her liver was not functioning properly,” he says.

The treatment, even at this public sector hospital, was too costly for this farmer of limited means to afford, so he sought official financial help. At his request, the hospital administration started putting together a file to ascertain whether Shameem qualified to be treated at the government’s expense. The process took about six months.

Shameem, in the meanwhile, started vomiting blood and Ghafoor took her to a private consultant in Multan. “I spent 400,000 rupees on her treatment,” he says.

Eventually, on a relative’s insistence, he took her to Lahore’s Mayo Hospital, the biggest public sector medical facility in Punjab. Doctors there said a liver transplant from India was the only treatment that could work for her. “It was not possible for me to bear the expenses [of the transplant] so I brought her home,” says Ghafoor. A few days later, she was no more, leaving behind a grieving husband and two sons and two daughters, aged between 10 and 18.

Gulzar Hussain is on an intravenous drip — almost always. This is his only coping mechanism against bodily fluids that are gathering inside his abdomen. These fluid deposits are commonly caused by the prolonged presence of the hepatitis C virus in the human body. His skin has become sallow over the last three months as his haemoglobin has dropped much below normal levels.

Gulzar Hussain can barely talk, let alone walk. “Three months ago, so many fluids were deposited in my stomach that I couldn’t move. I was taken to [a government-run] liver treatment centre in Faisalabad where doctors drained the fluids with the help of a big syringe.” Now that the deposits have gathered again, he says, he does not have money to even travel to Faisalabad — only 40 kilometres away from his village of Chak 119.

Faisalabad maybe too far away for him but the tehsil headquarters hospital in Jaranwala is only a few kilometres away from his village and not much money is required to reach there. He does not go even there and, instead, has been seeking treatment from a local quack who administers medicine and injections from the comfort of his charpoy, usually laid out on the street outside his house during the day.

Gulzar Hussain knows the quack is not a certified medical practitioner. He also knows that hepatitis C is rampant in his village – nearly every household has one or two people suffering from it – and that it has spread mainly due to the unsterilised syringes the quacks in the area use. But he still calls them “a blessing for the poor”. If there were no quacks around, he says, “how would I get cheap treatment at home?”

In another part of the province, Niamat Bibi also relies on quacks operating near her village, 105-WB in Vehari district. She lives with her husband and seven children in a humble two-room house given to her by a landlord for whom she and her entire family work.

Niamat Bibi has been suffering from hepatitis C for two years but does not have the money to travel to a government hospital in Vehari (around 18 kilometres from her home). The journey costs a minimum of 100 rupees and also requires taking time off work without any wages. She says she cannot afford that. “We are too poor to afford three meals a day,” she says.

To save on cost, she had herself checked at a laboratory near her village. The lab charged 800 rupees to carry out her blood tests, which confirmed that she was suffering from hepatitis C. She also needs a Polymerase Chain Reaction (PCR) test to ascertain the extent of liver damage but it costs 5,000 rupees. “I do not have that much money,” says Niamat Bibi.

She regularly visits a local quack who injects her with steroids that make her feel better. “Whenever I am in pain, I visit the doctor at his clinic and he gives me a few tablets along with an injection. The medicine and injection make me so fit in a few hours that I can work in the fields again.”

The village of Mukhiana is linked to one of Punjab’s romantic legends. It is around 28 kilometres to the north-east of Jhang city and has a number of old crumbling buildings on its periphery, including a grand mansion built by Khewa Khan who once ruled Jhang and happened to be the father of Sahiban, the damsel who fell in love with Mirza, the son of a peasant. Sahiban’s brother and his soldiers killed Mirza while he was resting under a bush during his flight to his village, Danabad, along with Sahiban.

Today another killer is prowling the area.

On March 14 this year, Punjab government set up a month-long camp to conduct a hepatitis C screening at Mukhiana’s rural health centre. “We screened 2,999 persons: 1,388 males and 1,611 females. Of these, 985 – or 32.84 per cent – were found to be hepatitis C positive,” says Dr Ashiq Hussain, medical superintendent of the health centre.

Muhammad Akmal, 47, a tall, barrel-chested man, stands outside Ashiq Hussain’s office on an April day in Mukhiana, holding his hepatitis vaccination card. He was diagnosed with hepatitis C a year ago after experiencing constant stomach aches and pain in other parts of the body. He is waiting to find out when he will get the report of his PCR test so that his treatment can start.

“I was told that I would receive a text message as soon as the report was ready but it has been more than a month and I have not received any message,” Akmal says. Ashiq Hussain explains that there is nothing he can do about the delay. “The samples for PCR were to go to a central lab in Lahore,” he says, “[but] the higher authorities have not yet collected them from us.”

Akmal is a poor farmer and has no money for private testing and treatment. He does what many impoverished villagers facing a problem do: visit a pir, a spiritual guru of sorts who is seen both as a healer and a purveyor of benediction. The pir gives him water to drink over which some religious texts have been recited. This has not improved his health.

Asif Shahzad, a district health officer in Faisalabad, says, “There is a common misconception that hepatitis C spreads through contaminated water — it has nothing to do with water.” Only hepatitis A and E, he says, spread through contaminated water but, fortunately, their prevalence is relatively low in Pakistan.

Hepatitis C, he says, is a blood-borne disease and spreads mainly through blood transfusion and the use of unsterilised surgical equipment and reused syringes. Contaminated sharp tools at gynaecology and maternity clinics also pose a grave risk of transmitting the virus from one person to another, he says. Unsterilised razors and scissors used by barbers also help it spread.

The Pakistan Medical Research Council, which works under the federal health ministry, conducted a nationwide survey in 2008 and found that 62 per cent of carriers of the hepatitis C virus had contracted it through reused syringes. Since such syringes are used either by drug addicts or by quacks. It is through them that the disease has been spreading widely and rapidly.

The survey also made some startling revelations: Punjab was found to have the highest prevalence of hepatitis C, at 6.7 per cent, followed closely by Sindh at five per cent. The other two provinces – Balochistan (at 1.5 per cent) and Khyber Pakhtunkhwa (at 1.1 per cent) – had almost negligible rates of the diseases. Seven districts where hepatitis C was found to be most prevalent – Vehari (at 13.1 per cent), Hafizabad (at 12.9 per cent), Pakpattan (at 10.6 per cent), Bahawalnagar (at 10.1 per cent), Bahawalpur (at 9.9 per cent), Okara (at 9.5 per cent) and Jhang (at 8.7 per cent) – are all in Punjab.

These numbers had been lying in government records for years – until the Punjab government took note and organised two separate week-long exercises over the last one year to gauge the incidence of hepatitis C, among other diseases. The first exercise was carried out between August 15 and August 19, 2017, and resulted in the blood screening of 236,246 men and women aged 14 years and above in all 36 districts of Punjab. The results showed that an alarming 17.2 per cent (40,739) of them had active hepatitis C virus in their bodies. In the second exercise, conducted between February 19 and February 24, 2018, blood samples of 760,655 people were screened from across Punjab. An astonishing 14.8 per cent (112,694 people) were found to have hepatitis C.

These results cannot be generalised since most people who participated in these exercises were either known to have hepatitis C or they suspected they had it, say officials at the Punjab Hepatitis Control Programme. However, they add that every ninth person in the province is suffering from hepatitis C and B. A decade ago, every 16th person was.

The programme officials have selected six districts – Vehari, Hafizabad, Jhang, Pakpattan, Okara and Faisalabad – to find out the causes of the disease and then carry out targeted interventions to remove those causes. In each of these districts, five union councils have been identified where 50-60 per cent of the people are reported to be suffering from hepatitis C. These union councils have been designated as hotspots. Extensive blood screening is being carried out.

Dr Zahida Sarwar, who heads the Punjab Hepatitis Control Programme, concedes that “the prevalence of hepatitis C has reached an all-time high level in the province”. The number of those suffering from the disease in Punjab is so high that the provincial government will have to “treat a minimum of 800,000 patients every year” to get rid of it. The existing medical facilities in the province are not equipped to handle such a large number.

So far only small steps have been taken. The Punjab Assembly passed a law in March this year to provide for monitoring, diagnosis and treatment of hepatitis C. The legislation is also aimed at enforcing measures to stem the spread of the disease through reused syringes, insecure blood transfusion and other means.

Sarwar is happy that the law has been approved but insists that there is a “dire” need for awareness about the causes for the spread of the disease. The most important step that she believes must be taken urgently is to introduce syringes that become automatically unusable after they have been used once.

Dr Asif Shahzad says the government should also “launch an awareness campaign against the quacks”. In order to wean people off them, he suggests that government-appointed doctors should go door-to-door to conduct medical check-ups in the village. Moreover, “the government should tell cable operators to stop airing advertisements promoting quacks and hakims”.

He also warns that quacks may prove too powerful to be checked with these measures. “Whenever we initiate a crackdown on them, we face huge resistance from powerful politicians. They call and ask us to spare the quacks who usually can sway voters for or against an election candidate,” he says. With elections looming large on the political horizon, he asks, “Is it possible to launch a successful crackdown in such circumstances?”

This was originally published in Herald's June 2018 issue under the headline 'Viral problem'. To read more, subscribe to the Herald in print.

The writer is a features editor at Sujag, a web venture aimed at sensitising people about local issues and politics.