They come in their hundreds every morning— except Friday, which is the holy day in Afghanistan—arriving in dribs and drabs to wait patiently for the Ali Abad orthopaedic clinic, which is run by the International Red Cross to open in Kabul. All suffering from some severe physical handicap, they are prepared to submit to any treatment that might restore the mobility they need to lead a normal life. Injuries sustained during the war, loss of limbs to landmines, accidents at work, the consequences of polio, scoliosis, arthritis, paralysis or just simply malnutrition are some of the everyday problems in a country like Afghanistan.
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| Photo WHO/Contrasto/Riccardo Venturi |
Fazillà, a 14-year-old girl, arrived on 19 May 2007. Her hospital number was 33062. Her father, a tall, silent man, carried her in, cradling her gently in his arms. Her mother followed, shielding the wasted, pain-racked body of her child. The pain came from sores caused by months spent lying practically immobile in bed, her only companion being her interminable suffering, which increased with every movement, night and day. No school, no sky, no sun, no clouds—nothing but the walls of the family’s humble home in Yaka Tut, one of the poorest districts in Kabul.
Until the age of 10, Fazillà had been a perfectly normal little girl, lively and active, a happy member of an extended family comprising parents, grandparents, five brothers and a sister. Then she began complaining of pain in her legs, which slowly, and excruciatingly, started creeping up her back, making walking more and more difficult with every day. They took her to the doctor, who diagnosed rheumatoid arthritis. This was in 2004. Despite the prescribed drugs, painkillers and anti-inflammatory drugs, the pain continued to intensify. Different prescriptions, more tests and X-rays revealed a serious scoliosis of the spine.
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| Photo WHO/Contrasto/Riccardo Venturi |
In 2005, a team of visiting doctors, specialising in paediatrics, carried out numerous tests at the Indira Gandhi Hospital. They suspected a tumour, which turned out to be a misdiagnosis.
Fazillà was sent home, but was no longer able to walk. Her spine was so deformed that she was doubled over. Even sitting was impossible. In the summer of 2006, her condition was finally correctly diagnosed: a very rare, insidious form of tuberculosis (TB) affecting the bones. Known as tubercular spondylitis or Pott’s disease, it is notoriously difficult to diagnose.
It was at this point that Fazillà was put on a standard treatment, which has been used for a decade against all forms of TB. It consists of a cocktail of antibiotics effective against Mycobacterium tuberculosis, the micro-organism that was slowly sapping the girl’s life. The full course lasts for eight months, during which time the tablets have to be taken regularly and punctually everyday, without disruptions.
Strict adherence to the prescribed schedule is the most important factor governing the efficacy of the treatment. In view of this, the World Health Organization (WHO) set up the Directly Observed Treatment Short-course (DOTS), providing for strict monitoring of the therapy for optimum therapeutic benefit. Applied since 1995 to more than 26 million people in 187 different countries, DOTS has led to the complete cure of the illness in 84 per cent of cases. The total cost of treatment for eight to nine months is a paltry $20.
When the DOTS course had been completed, Fazillà was tested again for TB, and this time the result was negative. There was not a single trace of the dreaded disease in her body. But sadly, in spite of the cure, there was no happy ending in this case. Fazillà’s bones had been irreversibly damaged, especially during the very vulnerable growth stage of adolescence. Although TB had been defeated and the degenerative process arrested, the consequences remained—the damage left behind in the wake of this unequal battle was devastating. Her spine, which will never be straight again, causes the muscles to contract throughout her pathetically wasted body, scarred as a result of her being bedridden for a long time.
At the Red Cross clinic, staff do their best to help Fazillà, alleviating her pain with medicines and providing some rehabilitation therapy. Supported in a cradle of foam rubber cushions, she is turned very gently almost every hour; little by little, the lesions will heal. Fed on a very high-calorie diet, five meals a day, she will eventually regain that modicum of energy necessary for attempting the first mild physiotherapy exercises. Perhaps, if things go well, she will be able to sit with the help of a brace and walk a few steps supported by a Zimmer frame. But there is a shadow over the future for Fazillà, with her sensitive face and dark deep-set eyes, bright with intelligence. No man in a country as poor as Afghanistan would dream of marrying a badly handicapped woman who could be of no help in the home.
A smile lights up Fazillà’s face when she talks about resuming her studies. As a bedridden invalid, she lost three years of schooling. She dreams about learning English. At the centre, there are teachers ready to help her, but at home how could she possibly attend school? Her case is even sadder considering that, had her illness been diagnosed early, she could have been completely cured in a matter of months, with very little expense and no need for hospitalization. The fact is that TB is not only controllable, but also curable.
The genome of tuberculosis has been even found in Egyptian mummies, and is as old as the history of man himself. It is easily recognizable, despite its various names and the diverse cultures in which it has surfaced throughout the centuries. TB was for centuries an almost inevitable death sentence for anyone who contracted it. Then one day in March 1882, Dr. Robert Koch, an obscure German doctor, reported that in the course of his experiments he had succeeded in discovering the hitherto unknown cause of the disease, which immediately helped save the world from the scourge of TB. By producing proof that its cause was a specific microscopic bacillus (Mycobacterium tuberculosis), Dr. Koch made diagnosis possible and laid the foundations for a therapeutic approach that, within only a few decades would enable the medical profession to treat TB, a disease which menaced mankind for thousands of years. Still, in spite of this, nearly 2 million people continue to die from TB every year—the figure quoted by WHO is 1.8 million, or 5,000 a day. Imagine reading in the paper day after day that 15 planes, each carrying 300 people, had crashed with no survivors. More devastating than malaria, which affects isolated regions plagued by mosquitoes, TB can infect anyone anywhere, as it is spread not through direct contact, but by airborne droplets.
WHO data also show that 2 billion people—one third of the world’s population—have been infected by the tuberculosis bacillus, although not everyone infected becomes ill. In nine out of ten cases, the bacillus remains latent and produces no symptoms. However, in the case of a weakened immune system, it becomes active, attacks the host body and prompts the outbreak of the full-blown disease. The populations in developing countries are the most vulnerable, because TB, AIDS and poverty go hand in hand. The most common form of tuberculosis is of the lungs or pulmonary TB, also known as “sill” in Afghanistan. The immediately recognizable symptoms are coughs, accompanied by the spitting of blood.
Ten years ago, 25-year-old Zakayeva, a Hazara woman pregnant with her fifth child while still breastfeeding the fourth, had watched her mother die of TB. Even before the cough started to rack havoc on her own chest, Zakayeva was not aware of the disease that was making her feel so tired, drenching her body with sweat and inducing icy shivers. Her family lives in extreme poverty, even by Afghanistani standards, in a country that is one of the poorest of the world. Her husband’s irregular income, a builder dependent on piecework, is frequently insufficient to feed the entire family, with four children and an old, sick grandfather, all living in a crowded single room, almost always in deep darkness as no light penetrates the gloom from the single north-facing window—even on sunny days. Still, Zakayeva’s smile is sweetness itself as, cradling her youngest in her arms, she said that from the day her TB treatment began, things have improved; she feels less tired and no longer suffers from headaches. She receives her free tablets from WHO and her treatment card entitles her to a sack of rice and a can of oil every month. These supplementary rations are provided by the World Food Programme (WFP), which collaborates with WHO in the fight against TB. However, one has to wonder how much of this will benefit Zakayeva, as Afghan women, like many in other Asian countries, will eat only the leftovers when all other family members, primarily men, have partaken.
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| Photo WHO/Contrasto/Riccardo Venturi |
One of the statistical records held by Afghanistan, is that women can expect to die earlier than men; the percentage of women succumbing to TB is far greater than that of men. According to Dr. Faizullah Kakar, Afghanistan’s Deputy Minister of Public Health, these two facts are related. Sexual discrimination forces women to live practically as recluses in homes that nearly always lack adequate ventilation, are overcrowded and often built with substandard walls. If you add the irritating effect on the lungs of smoke from using coal for cooking, it is only too easy to understand why a person already weakened by malnutrition becomes a victim of diseases, among which TB predominates.
Fortunately, the situation in Afghanistan has improved over the last three to four years. According to information released by the Ministry of Health, out of the 44 per cent of TB patients monitored by the DOTS system, the majority have been completely cured. Zakayeva will be cured and will give birth to a healthy child. Her family members stand a good chance of escaping infection because, after the first month of treatment, TB ceases to be contagious. Not everyone, however, will be so lucky, especially in the years to come. This is what worries Dr. Kharam Shah, who, having organized a TB programme in Pakistan, has been sent by the United Nations to do to a similar job in Afghanistan.
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| Photo WHO/Contrasto/Riccardo Venturi |
“At the moment”, he says, “the fight against TB, as is the case with other diseases, is producing a good rate of success. In Kabul, the situation in the hospitals, doctors’ surgeries and clinics has improved enormously in comparison with past years. The problem is that all this improvement is due solely to the support of the humanitarian organizations and the funding that Afghanistan receives from abroad. This makes for a situation that is fragile and unsustainable in the long term, like a patient kept alive by oxygen who, as soon as the supply is switched off, will inevitably die.”
Anna Cataldi, who served as UN Messenger of Peace from 1998 to 2007, has joined the global fight against tuberculosis and has been appointed as an Ambassador of the Stop TB Partnership, a network of more than 500 international organizations, countries, private and public donors, TB patients and non-governmental organizations. The Stop TB Partnership, whose secretariat is hosted by WHO, raises awareness worldwide about the unfair burden of tuberculosis on refugees, migrants, people living in poverty and other disadvantaged groups. Ms. Cataldi is also the author of Letters from Sarajevo, which chronicled the impact of war on Bosnian children.
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