​​An untold story from Ratodero

Larkana is located in the northwest of Sindh Province. It's the fourth largest city in Sindh. It is also called the city of Holy Alams (flags considered a sacred symbol for Shia Muslims). The city has historical significance and it's home to famous political leaders such as Zulfiqar Ali Bhutto, Murtaza Bhutto, and Benazir Bhutto. The land is enormously fertile. It produces all kinds of crops, fruits and vegetables: rice, maize, cotton, wheat, mustard, and sugarcane. However, Larkana is the famous for its unique crop of guava and known to be the guava hub of the province.

Zohra was in her early forties, a typical woman from rural Sindh; tall, with sunburnt skin and rough hands from working in the fields.

She said she had been trying to get pregnant since she got married at the age of 14. Her husband was 15 years older than her. When, after 15 years of marriage, she got pregnant, she was happy to see her tummy swell and get bigger day by day. But her pregnancy ended up in intrauterine death (she gave birth to a dead child). She was in pain and her husband was in the fields. When he came home in the evening he couldn't arrange transport to get to the hospital.By midnight, she was bleeding heavily, and they called a “Dai" (an untrained birth attendants  mostly serving rural settings). She could not help and eventually, they had to wait until morning.

Soon after, she was pregnant again. This time it was high blood pressure.

Her sister, who was two years younger than her, was also struggling in her own life. She had five daughters and her husband wanted a male child. She promised Zohra that she would give her child to her the instant the child was born. And she did, she gave little Imad over to her sister.

Imdad was three years old when he was diagnosed with Situs Inversus dextrocardia. He needed a major surgery (major aortopulmonary collateral artery coiling followed by a total repair). The family waited for the coming wheat harvest season when they could earn some money, and enough grains and resources, to pay for his treatment. During this time, Imdad continued to have episodes of breathlessness, turning blue and pale on occasions, the skin of the fingers and fore toes turned a darker tint of blue. Till then, he got treatment from the local doctor, Muzafar Ghangro, who had a clinic nearby and charged them 30 Pakistani rupee (PKR)  per visit. He was supposed to be the best doctor in that vicinity who knew pediatric ailments well. He treated almost every child with injections and intravenous drips.

One of their relatives, who was in the army, suggested taking Imad to the Armed Forces Hospital in Rawalpindi. The family borrowed some money from their relatives, bought economy class train tickets, and traveled to Rawalpindi. The hospital offered them a 50% discount as they had an armed forces personnel reference. 

In April 2019, the WHO declared an HIV outbreak in the Ratodero area of Larkana as a Grade 2 Emergency. The vast majority of sufferers were children. This was not the first time that HIV had hit Larkana. The first HIV case can be traced back to 1995. Eight years later, in 2003, the city garnered attention when the first outbreak of HIV among injecting drug users (IVDUs) was reported. Out of 175 IVDUs, 17 were confirmed positive. And now this.

Pakistan has a long-standing history of unsafe medical practices, reuse of injections, equipment, and drips by untrained health care providers and dentists, self-trained birth attendants and gynecologists, especially in the rural areas. Drug abuse, unprotected sex, unsafe abortions, prostitution, and polygamy; which happen under the table also secretly contribute to the worsening tragedy.

Larkana always had all the essential elements of an impending HIV epidemic. There was a sudden rise in the number of HIV-positive people in the district, exceeding the 1,200 cases in 2016. After circulating for two decades in the high-risk population, combined with illegal blood banks, poor infection control practices, widespread use of unsterilized syringes, meager basic healthcare facilities, and untrained healthcare workers, the virus inevitably found its way to the general population. Currently, more than 900 children are on antiretroviral therapy at the Tehsil Headquarter Hospital in Ratodero. However, there's still no active surveillance system for HIV in Pakistan and cases are under-reported due to a lack of screening and cultural taboos.

Imdad underwent pre-operative screening and consultation. The hospital offered the family a discount after which they paid 300,000 PKR. Two days before the operation, the surgeon called and told Zohra and her husband that their son was HIV positive, and they couldn't operate on HIV positive patients in the hospital.

Imdad is still taking antiretroviral therapy from the Tehsil Headquarter Hospital in Ratodero. He is shy, looks mostly healthy, but is a little pale and underweight. Zohra wishes that he didn't have cardiac issues and regrets ever taking him to Dr. Muzaffar.​

DISCLAIMER: ​Copyright belongs to the author. This blog cannot be held responsible for events bearing overt resemblance to any actual occurrences. The views expressed do not necessarily reflect the views and policies of CCIT or AKU.​

About the Author

Headshot.jpgRabab is a researcher and Epidemiologist, PhD fellow working with the Department of Pediatrics and Child Health at the Aga Khan University, Karachi, Pakistan. She discovered a passion for Epidemiology while attending the Sind Institute of Urology and Transplantation witnessing illness, pain, renal failure, liver failure, arteriovenous fistulas, dialysis, pale faces, swollen or emaciated bodies, wondering what lead to their illnesses. Primary prevention rather than tertiary care.