The health crisis in Hyderabad

A doctor led the way through the paediatric ward of Liaquat University Hospital in Hyderabad and gestured towards a small cubicle where a distraught young mother sat with a small infant in her arms, a drip making its looping way to a nearby stand from a point on one of the child's hands. "This six month old was brought to us in a severely dehydrated condition because of diarrhoea," the doctor, who introduced himself by the single name Ijaz, told IRIN. He turned around and looked at the cubicle directly opposite where another mother lay exhausted next to a child with unnaturally large eyes and sunken cheeks. "When this child was brought here, he was almost completely bereft of bodily fluids. We've had to rehydrate him with saline drips for the past two days, but he's still very weak," Ijaz explained. In the rest of the ward, children ranging in age from just a few months to about three years lay in various states of discomfort, all with intravenous drips attached to their arms or hands. The high-pitched wail of an infant from across the room was matched by another from one closer by, while a child, described as being about two years old by the doctor on duty, obviously in great discomfort, lolled from side to side as his tear-stricken mother tried to ease his pain. Ijaz, the doctor on duty, appeared unaffected by the depressing sight. "The situation is actually better now," he said. "This contaminated water has created lots of problems but the situation has improved a lot now." CONTAMINATED WATER Because of a contaminated water supply in Hyderabad, a historic city in the southern province of Sindh, about 155 km from the provincial capital, Karachi, 34 people, mostly children, have died and more than 4,000 others have been treated for severe gastric illnesses since the crisis broke in mid-May, according to provincial health officials. Local residents, including government health officials in Hyderabad, allege that the contamination was caused by irrigation officials mistakenly releasing poisonous water from a nearby lake into the river Indus that passes through the province before disgorging its contents into the Arabian Sea. "After water from Manchar Lake was released into the Indus by irrigation officials the chloride content or the salt content was increased many times," Dr Masood Ahmed Solangi, the official in charge of paramedical services at the DG Health Services office, told IRIN. Alarmed by the crisis, the United Nations immediately constituted a disaster management team, sending joint WHO-UNICEF teams to the stricken region to assess the situation. "A WHO team came here last week, with Dr Khalif Bille - the WHO country representative for Pakistan - and he personally went to a filtration plant which is said to be out of order," Solangi explained. The team found that the de-chlorination plant was out of order and that Water and Sanitation Agency (WASA) officials were just using bleaching and other methods which were not sufficient to counter the contamination, he said. Now, although the quality of water was "improving day by day" because irrigation officials had subsequently started pumping water from a barrage upstream into the river Indus, the six government hospitals in Hyderabad were still reporting cases of diarrhoea - which was not uncommon in the summer with temperatures in excess of 40 degrees centigrade, Solangi said. Other health officials, including a diarrhoeal specialist at the DG Health's office, backed Solangi's assertion that "the situation was now improving" and that "diarrhoea was not uncommon" in a Hyderabad summer. UNDER CONTROL? "It is not a critical position at present. It has been controlled by all the authorities involved. We have controlled it," Dr Mir Mohammed Sheikh, the health department's diarrhoeal control specialist, told IRIN. He repeated Solangi's assertion that diarrhoea "always happens in this season" and that the high number of casualties and patients because of the contaminated water could also have been added to by a common seasonal upsurge in the illness. Later, Dr Hussain Bux Memon, the director-general of health, backed his officials as he told IRIN that his department had to deal with "plenty of cases of diarrhoea every year". "This is not new, although of course the number has been raised by 15 to 20 percent," he emphasised. But the health department "had left no stone unturned" as they provided "all possible facilities to patients" brought to government hospitals, Memon stressed. However, he admitted that the problems caused by the contaminated water could have been avoided, had there been a properly functioning water filtration process. "We have to completely confess that these deaths are our [the local administration's] fault. We don't have the facility to filter the water. We are giving untreated water to the community and, of course, it is a problem," he said. But the non-functioning of one of Hyderabad's two main water treatment plants was a problem that required the intervention of federal, provincial and local water supply bodies before the problem could be solved, Memon said. "A lot of money is required to refurbish these plants," he said. The local administration had received much support from WHO and UNICEF, Memon said. "WHO had sent experts in earlier to assess the situation. Now, today, they are sending an engineer to assist with the technical problems faced by WASA," he explained. UNICEF, meanwhile, was assisting the local administration by helping with an awareness campaign in the media, and also by supplying chlorine tablets, as well as training over 600 field workers - known as Lady Health Workers (LHWs) - who would go from house to house to show families how to treat tap water themselves, Memon said. PROBLEM REMAINS Hyderabad, though, was still in a state of medical emergency "because we are getting new cases every day", Memon said. At the Liaquat University Hospital, a government-run institution, Dr Hadi Bux Jatoi, who heads the facility as its medical superintendent (MS) and is a former DG Health himself, echoed Memon's words as he told IRIN that many new cases were being reported every day. "We are still receiving new cases. There were 126 cases reported just yesterday," he explained. The total of deaths, reported up to Thursday to government hospitals, was 34, but Jatoi said there could be many more deaths that might have occurred in the region's outlying areas or not reported to government authorities. "The number of deaths reported are the ones who have been certified by government hospitals," he maintained, adding that the Liaquat University Hospital alone had certified 22 deaths. Since Jatoi is also the chairman of a special monitoring cell constituted by the government of Sindh and mandated to provide daily updates to authorities at the provincial level, he produced a list of patients that had either died in hospitals or been received dead on arrival. "The number of patients admitted to hospitals is 4,145. Out of these, 34 have died," he said. And of these, 26 were children, Jatoi said. "The water has affected those children who are under-nourished, who are weak, so they are more affected," he said. But Jatoi refused to back his colleagues from the health department who had insisted earlier that the situation was now slowly coming under control. "The situation is not improving because the mortality rate is higher in patients who are now being brought to hospitals," he emphasised. And the problem seemed to have been compounded more by WASA officials, who, in their eagerness to treat the water coming from the malfunctioning treatment plant, had been liberally adding more chlorine than the water appeared to need, he said. "They don't know how much chlorine should be added to the water. They are not technically sound. I think we might face another situation where the water gets super-chlorinated and we might start receiving patients from that point of view," he said. The WHO team which had taken samples of the water earlier had discovered that "none of the water was satisfactory by WHO standards", Jatoi said. The medical superintendent called for a "complete study" to be conducted to ascertain "just what was present in the water". "If there were certain metals present in the water, they should be recognised and the treatment should be done accordingly. So it needs a thorough study and the community should be given proper instructions about how to use the water," he said. CRISIS MANAGEMENT A task force, established by the local administration with WHO help and UNICEF input, consisting of 10 members - mostly engineers and doctors - was now going to look into the "water aspects" of the problem, Dr Ghulam Nabi Kazi, WHO's provincial operations officer for Sindh, told IRIN in Karachi. A WHO environmental health expert had been flown in from Jordan to assess the problem with the water treatment plants and he sat in on a meeting with local administration officials on Thursday where the decision to establish the task force was made as authorities tried to work out how to tackle the situation, Kazi said. "WHO and UNICEF are jointly supporting the local administration as we have also decided to introduce a community-based initiative to handle the situation," he explained. A UNICEF official, who told IRIN a day earlier that UNICEF was supporting the training of over 600 health workers as part of an awareness campaign on how to use chlorine tablets or powder at home, had also stressed the same point. "This is being seen as a health problem and a technical problem and a Water and Sanitation Authority (WASA) problem but this is [also] a social problem now. So why not get the social movers and shakers involved in this - that is the political representatives right down to the village level where you have a councillor and an entire village council and every village has a councillor itself - to get them to understand the gravity of the situation and to involve them in raising awareness at the community and family level?" Raana Syed, the UNICEF provincial head for Sindh, told IRIN in Karachi. "So we're offering support because eventually it has to be a community-based action as well. You cannot just rely on hospitals and service providers. It has to be communities first understanding the situation and then taking action to protect themselves," she maintained. Apart from UNICEF's support for LHWs, the UN agency was also offering support for the training of other health care providers if needed at a later stage, Syed explained. "The other thing is support for a mass media campaign on the local media, in local channels of communication, and support for monitoring the quality of water in terms of capacity building for testing and working with the Ministry of Science and Technology on how to establish an ongoing monitoring and testing system to make sure that this kind of a tragedy doesn't happen again," she said.