Reflection by: Sindh Monitor – Translation by: Dr Khalid Zaman
The health situation in the Sindh province of Pakistan, specifically pertaining to those epidemics preventable and manageable, reflects a general lack of concern and commitment to the Sindhi people by the central Pakistan government. Using government reported facts, clear levels of inadequate health funding are shown. To demonstrate this point, the following article highlights cases of Hepatitis and Dengue Fever currently raging across the Sindh province and then reports on the general dismissal of these scourges by the Pakistan government. It then summarizes inadequacies in accepted health care standard measurements. Devaluing the lives of Sindhi people is a clear form of discrimination, and the handling of these epidemics requires international review.
2.96 Million people are said to have contracted hepatitis in the Sindh province of Pakistan. 75,000 patients are expected to be treated under Sindh Chief Minister’s Heath plan, but only 11,000 patients have received treatment so far. Only 0.6 million people have been vaccinated. These numbers were released by the Department of Health, Sindh few days ago. The Health Department reported that hepatitis cases are rapidly growing in the province of Sindh and soon may become a huge public health problem. Another report released by the Federal Health Ministry indicated that there may be as many as 40,000,000 cases of Hepatitis B and 7,840,000 cases of Hepatitis C in the country. In the province of Sindh alone there are 1,000,000 cases of Hepatitis B and 19,60,000 cases of Hepatitis C. Using these numbers, 2.5% of population of Sindh province suffer from Hepatitis B and 4.9% from Hepatitis C. At this time, one-fifth of these cases are considered chronic.
A survey has discovered that more residents of Sindh receive medical treatments with injections than the residents of the other provinces. The average injection rate in Sindh is 13 per head per year. This method has major harmful health related results and is not an ideal form of vaccination or treatment. More than 47% of these injections are given under substandard conditions without taking recommended medical precautions. About 90% women in the province do not know that reusing syringes can spread hepatitis. 9.84% of cases are acquired by the infected needles, 1.09% cases occurs from used blood products and 4.37% cases are result of blood transfusion. Federal and Sindh governments are said to have taken initiatives for the disease control but the claimed and available resources are inadequate to meet the needs of this major public health problem.
Under the Prime Minister’s Federal Disease Control Program, 50,000 vaccines and 36,000 screening kits are distributed among the public every year. 800 patients are tested by the Polymerase Chain Reaction (PCR) method each month. The Federal Health Ministry has reported that 1,740 patients of Hepatitis B and 2,500 patients of Hepatitis C are treated in the Sindh province every month. The Federal Health report admits that only one person out of 800 receives the vaccine, only one out of 86 patients was supplied with a screening kit, and only one out of 6000 Hepatitis B and 450 Hepatitis C patients are receiving treatment under this program.
The Sindh Government started its own disease control program in October 2008 to deal with the hepatitis outbreak. The Sindh Government has allocated 2,704,600,000 rupees to be spent over a three-year period. Under this three-year plan, the hepatitis vaccine is supposed to be made available to 4.2 million newborn babies, 30,000 citizens, 58,500 high-risk people and 35,000 prison inmates. In addition, 70,000 patients with Hepatitis C and 7,500 patients with Hepatitis B will be treated as well. Under this program PCR laboratories are to be set up in the district headquarters of Mir Pur Khas, Sakkhar and Larkano. Cold chain facilities for diagnosis and storage are to be established in Hyderabad, Sakkhar, Larkano, and Jamshoro districts. Free treatment camps are to be installed in the areas where the infections are spreading rapidly. The estimated cast of providing diagnostic test is 3,000 rupees per person. Treatment costs of 40,000 rupees per patient for Hepatitis B and 40,000 to 50,000 rupees per patient for Hepatitis C have been approved.
Under this health plan 0.6 million people are projected to be vaccinated against Hepatitis B in a year. To date 0.45 million citizens, 150,000 children and 7,000 prison inmates have been reportedly vaccinated. Under this provincial plan 2,696 patients with Hepatitis B will be treated this year. To date, only 310 patients and 820 inmates have received treatment. 14,860 Hepatitis C patients are targeted to be treated this year; about 10,000 patients have been reportedly treated.
An honest review of the government-issued health reports suggest that government has not been able to take adequate measures to control this public health problem. Even if we combine the federal and provincial figures, clearly only a small fraction of estimated 2.96 million patients have been attended – only 0.6 million citizens have been vaccinated and about 15,000 patients treated. Additionally, the credibility of the figures provided by government sources has not been confirmed. Some sectors are recommending independent data collection to ensure that treated patients are, in fact, disease free and no longer infectious to others. Many public health experts in agree that the infection can spread exponentially in Sindh in the coming years if aggressive prophylactic and curatives measures are not taken immediately.
II. Dengue Fever and the Steps Taken to Deal With It
The first case of Dengue fever was identified in 1994 in Karachi, Sindh. Several patients with this illness died because of the lack of sophisticated diagnostic and curative means. Dengue fever emerged again in October 2006. During the 12 year lapse, little has changed regarding the region’s ability to combat the illness.
Dengue fever is caused by several related viruses (four different arboviruses) . The virus is contracted from the bite of a striped Aedes aegypti mosquito that has previously bitten an infected person. The mosquito flourishes during rainy seasons but can breed in water-filled flower-pots, plastic bags, household water reservoirs and terra cotta pots year round. One mosquito bite can inflict the disease. The virus is not contagious and cannot be spread directly from person to person. There must be a person-to-mosquito- to-another- person pathway.There are two presentations of the viral illness in Sindh, Dengue fever and Dengue hemorrhagic fever.
Dengue fever begins with sudden high fever. The other signs and symptoms include: headache, especially behind the eyes, muscle and joint ache, red rash, increased sensitivity of skin, nausea, vomiting, swollen lymph nodes, fatigue and dizziness. Tests that may be done to diagnose this condition include: antibody titer for dengue virus types, complete blood count, serology studies to look for antibodies to dengue viruses. The condition generally lasts a week or more. Although uncomfortable, it is not deadly. Full recovery is expected.
A small number of these patients develop into Dengue hemorrhagic fever. Patients with Dengue hemorrhagic fever experience additional symptoms of: restlessness, irritability, small bleeds under skin, in severe cases bleeding from the nose and ears, blood in the urine and stool, and a shock-like state characterized by cold, clammy extremities and sweats. Shock may cause death. Patients lose blood components and become prone to other infections and easy bruising. Treatment of Dengue hemorrhagic fever iconsists of not only treating the symptoms and vascular shock, but antibiotics and replacement of depleted blood constituents. The mortality, or death rate, with Dengue hemorrhagic fever ranges from 6% – 30%. Most deaths occur in children and infants.
The Sindh government has established emergency centers in tertiary hospitals and bigger districts hospitals to provide care for patients with this infection. The majority of patients are treated in hospitals in Karachi and Hyderabad, Sindh. Very few hospitals in Sindh are able to isolate blood constituents from whole blood. Expensive machines called platelet agitators are available in only a few hospitals in Karachi and Hyderabad. This offers little medical support to those contracting the illness in rural areas. It has been estimated that 40% of Dengue patients treated in Hyderabad’s Main Hospital came from area out side Hyderabad district.
Because this virus can be transmitted from one person to another via mosquito bite, it is important to isolate the patients until they are no longer infectious. Not many hospitals in Sindh have stringent isolation units to prevent the spread of the virus to other patients.
Clothing, mosquito repellent and netting can help reduce exposure to mosquitoes. The large-scale prevention of dengue requires control or eradication of the mosquitoes carrying the virus that causes dengue.
The Sindh Governments Health Division has directed hospital staff to identify the villages from where dengue patients are coming. They are instructed to work with malaria control teams (another common infection spread by mosquitoes) to help with mosquito abatement programs. They are required to report dengue cases to the District Health Office and the Directorate of Malaria Control.
Sindh Government’s initiatives to decrease mosquitoes in this province plagued by dengue fever have been thus far ineffective. The government of Sindh has issued a report stating that 700 patients with Dengue fever arrived in various hospitals in Sindh since January 2009. Nine of them did not survive – eight died in Karachi hospitals and one in Hyderabad. Even though the mortality rate is a little more 1%, the main reason for these preventable deaths is said to be delay in diagnosis, according to hospital’s spokesperson Dr Abdul Rasheed Memon.
III. Health Care Funding, Maternal Mortality Rates and Declining Quality of Government-Run Facilities
Sindh’s Health Ministry’s official report is a confession of the fact that the Health Department’s multi-faced initiatives to prevent various diseases have not yielded satisfactory results. Some independent sources believe that Health Department of Sindh’s performance has deteriorated in recent years. Numerous reports from international agencies have indicated that mortality rates of newborn babies and mothers are higher in the province Sindh than other regions of Pakistan. Statistical figures of various infectious diseases such as HIV and Hepatitis in Sindh are also worse than other provinces.
The Sindh Government has allocated 16,000,000,000 rupees for the health department in the current fiscal year’s budget. 10,560,000,000 rupees are for ongoing projects while
5,230,000,000 rupees are for new programs.
The government claims that 17 large-scale projects at federal and provincial level are underway for vaccination, disease control and overall health improvement. Independent observers are taking the government’s figures with grain of salt. They wonder why Sindh has the highest infection and mortality rate if the governments are spending about 20,000,000,000 rupees each year on health projects in Sindh.
Sindh Government’s report in connection with the health policy for years 2010 – 2015 has confirmed that the health situation in Sindh was much better than other provinces in 1980s. Surveys conducted by international and local agencies show that the health situation in Sindh started deteriorating in the mid – 90s. The World Bank’s report of 1996 declared high infection rates in Sindh.
According to Pakistan’s Public Health and Demographic Survey (PPHS) 2006 – 2007, the maternal mortality rate in the country was 27.6 deaths per 1000 live births, while the rate in Sindh was 31.4 per 1000 live births. Infant mortality rate overall in Pakistan was 78 per 1000 live births, while in Sindh it is 81 per 1000 live births. The neonatal mortality rate in the country is 94 per 1000 live births while the same rate in Sindh Province is higher at 101 per 1000 live births. Only 38% of babies are born in hospitals or at home with the help of trained nurses or midwives in Sindh. More than two- thirds of babies are born at home without the assistance from properly trained midwives in rural Sindh, with 23% of babies born with help of untrained midwives in urban areas of Sindh. 37% of children fewer than 5 years of age are reported to be under weight or undernourished in Sindh.
Only urban areas like Karachi have technologically advanced hospitals, while more than two-thirds of the Sindhi population live in rural and remote areas in dire need of these facilites. It is noteworthy to fully understand the significance of this (and other statistics) that a significant number of Karachi inhabitants are settlers who have moved to Karachi from other areas, and not indigenous Sindhi people.
The above-mentioned survey reported the highest number of HIV positive and AIDS cases in Sindh. Only 772 AIDS patients have been registered with ‘Sindh AIDS Control Program’, out of a total of 45,000 patients. 30-34% patients are known drug abusers who share needles. 1.2% of the patients are young men and 10.2 % are eunuch beggars. This report admits that fewer patients prefer to go to government facilities for treatment. This speaks to the bad reputation, substandard amenities and lack of trained staff at government hospitals. Similarly representative of this trend, of pregnant women who need and can afford to go to a hospital, 49% pregnant women use private hospitals while 36% go to government centers for treatment. Overall 75% of people seek treatment at private clinics and hospitals rather than use government run facilities.
Some experts believe that one of the many reasons for declining quality of healthcare in government hospitals is lack of trust and communication between direct health care providers and administrative officials. There is huge need for well-trained medical personnel, especially women at all levels – from basic health units to secondary and tertiary facilities. Some disadvantaged rural areas do not have health facilities, while others are severely under staffed and under budgeted. Because of the lack of trained medical personnel, quacks and non-qualified people have filled the void. These untrained providers do not take proper precautions or use aseptic techniques and thus worsen the spread of infectious diseases. Public campaigns additionally are not utilized to combat preventable diseases and death. Efforts not been made to educate rural populations about public health issues, such as the ill effects of reusing syringes in clinics and razors at barber-shops.
Social factors such as pressure of poverty, low education rates in the province, and political favoritism pose significant resistance to improvement in the health department’s functioning and fair allocation of resources. The influx of outsiders to the Sindh province is also seen as a factor in compromising the available resources for the people of Sindh. The effectiveness of the health system in Sindh faces many challenges: insufficient personnel, inadequate medical supplies and equipment, lack of quality control, flawed infrastructure, poor administration, operation, planning and execution to name a few.
The public is raising eyebrows at the failure of the Health Department to provide the minimum necessary health care to the people of Sindh, in spite of claims of huge expenditures of about 15 to 20 billion rupees every year. Infectious diseases are spreading like wild fire, mortality rates are on the rise and poor people in rural areas are dying every hour due to lack of proper health care facilities. The people of Sindh have lost trust in the Health Department. The people of rural Sindh perceive a lack of sensitivity by Health Department officials. Only a revolution in the provision of health care in Sindh can address this crisis. When the government itself acknowledges the inadequate outcome of their efforts, one wonders where is this money being spent? There needs to be a fair appraisal of the situation and that those people involved be held accountable.
 The following is a response to a health report originally printed in the Daily Kawish, a Sindh newspaper available in print and online at http://www.dailykawish. com/. The article was found January 30th, 2010, and prompted this discussion piece. All opinions are those of the Sindh Monitor and independent of Daily Kawish stances.
About the Translator: Dr. Khalid Zaman has a strong interest human rights. He was a charter member of the World Sindhi Institute, has emceed fundraising events and networked with Sindhis in the United States and abroad. He has participated in human rights vigils and demonstrations, and attended the United Nations Human Rights Conference in Geneva in the spring of 2008. He currently resides in Hawaii and serves on the Board of Directors for the Sindhi American Political Action Committee.
Courtesy: 4th Edition, SINDH MONITOR, Compiled by Munawar Laghari, Sindhi Human Rights Activist