Focus on the disfiguring skin disease leishmaniasis

Sitting on her bed at the Maywand hospital skin centre in the Afghan capital, Kabul, 70-year-old Amena can barely lift her arm. Her limbs, hands and face are marked by the first signs of leishmaniasis, a disfiguring and disabling skin disease affecting hundreds of thousands of people in Afghanistan. "I feel better now," she told IRIN. "I didn't know I could get treatment and was worried it would only get worse." But Amena is one of the lucky few. Most people infected with leishmaniasis go without medical treatment altogether, with the result that the disease is spreading quickly in this city of two million. "We have a major epidemic now in Kabul," Loretta Hieber Girardet, a spokeswoman for the World Health Organisation (WHO), told IRIN in Kabul. "An estimated 200,000 have the disease, or 10 percent of the population." Known locally as saldana, or one-year sore, leishmaniasis is linked to poor social conditions - particularly lack of hygiene and poor waste disposal. It is caused by a parasite transmitted by a sandfly. Sandflies inhabit the dried mud often used as building material for the construction of houses in Afghanistan, or around latrines. Starting with a lesion on the part of the body that has been bitten, the disease subsequently leads to severe scarring. According to the World Health Organisation (WHO), there are two types of leishmaniasis. The most common type is urban, or anthroponotic, meaning it is transmitted from humans to humans, while rural, or zoonotic, leishmanisis stems from the interaction of humans with rodents. In Kabul and other urban areas, the sandfly often bites at night. "Because the sandfly tends to bite at night, it's the exposed parts of the body - face, feet and hands - that are the most vulnerable," Girardet said. But it is often the social stigmatisation of leishmaniasis that is more painful than the disease itself - particularly for women. In Afghan society, a girl whose face is scarred by this disease may not be considered a prime candidate for marriage, hence inhibiting her chances for a normal future. Sadly, the disease has yet to receive the international attention it deserves. For the past 10 years, WHO and others have requested funds to treat or respond to the disease, but as it is not considered life-threatening, little donor support has been forthcoming. In a country like Afghanistan - where measles kills 35,000 children a year and diarrhoea, 85,000 - donors have tended to focus on the major killers instead. However, as the number of cases grows exponentially, the problem will only worsen - with more serious implications than are readily understood. "For every person who has leishmaniasis not treated, the likelihood is that they will infect one, 10, 15, 20 other people," Girardet said. Infection results from the sandfly picking up the parasites of the disease when biting the sore of an infected individual, and subsequently transmitting these in the course of biting another individual, she explained. A challenge facing health workers in the country is the general lack of awareness of the disease. Like Amena, many Afghans do not know how it is transmitted, do not recognise the symptoms, and often wait until the ulcer has spread before seeking medical attention. This in turn increases the risk of intensive scarring. But, ironically, leishmaniasis can be completely cured provided treatment is administered. Injected directly into the ulcer - or intra-muscularly for severe cases - patients are treated with the drug Pentostam or Glucantine for between eight to 14 days, depending on the severity of the infection. Girardet said the treatment cost between US $15 and $20, but the fact that most civil servants in the country, for example, earn as little as $30 per month renders cost irrelevant. "Put that into perspective - that money simply doesn't exist here," she asserted. Meanwhile, back at the Maywand skin centre - one of six clinics in Kabul dealing with leishmaniasis - the implications and effects of the disease are more apparent. With a lack of medicine to deal with the problem, many patients are simply turned away. "We used to have a lot more people coming here, but as people know we don't have enough medicine, they aren't coming," Dr Abdulmatin Baha, one of 10 dermatologists at the centre, told IRIN. According to the 30-year-old physician, the centre was dispensing four bottles of medicine a day at a time when WHO was providing it with 16 bottles a month. Now, however, even that supply was no longer forthcoming, he explained. Meanwhile, the clinic could still treat patients if they brought their own medicine, but instances of anyone doing so were rare. "WHO is providing us [with] less medicine than before. I don't understand why they aren't giving us more," Baha said. "I don't know how we are going to cope." Of the 200 people attending the centre daily, at least 70 were infected with leishmaniasis, he added. Sharing his frustration, Bibi Hawa, a 69-year-old grandmother, now on her third day of treatment, told IRIN no one could understand the horror of this disease unless they saw it every day in the mirror. "No one should have to live like this," she said, pointing to a large infectious lesion on her forehead. In an effort to tackle the problem, WHO recently appealed for $1.2 million to fund a major campaign to contain the disease and treat patients infected by it. "A little over $1 million is all we need to fund a two-year programme that would have a huge, long-term impact on this disfiguring disease once and for all," WHO Director-General Dr Gro Harlem Bruntland said in June. "But we need to act now: if this opportunity is missed, there will be a severe increase in the number of cases next year," she added, referring to that fact that returning Afghan refugees face a heightened risk of catching the disease. "We've had an increase of 200,000 people in the last few months to Kabul who are more at risk of the disease - as are international aid workers. They don't have immunity to this," Girardet noted. Focusing on preventive measures and the need for early medical attention, WHO is now working with local Afghan media to raise awareness among the general public. Measures applied to combating leishmaniasis are similar to those for malaria, including the use of bed nets and spraying with insecticides. Special attention must be paid to spraying the walls of buildings accommodating both humans and animals, and rubbish heaps. The NGO, Healthnet International, has also tried a novel approach, which entails impregnating chadors - the traditional veils worn by women - with insecticide. Meanwhile, work to restore the Kabul-based Institute of Malaria and Parasitic Diseases, which was completely destroyed during Mujahidin factional fighting of the early 1990s, is now in progress. Once it is completed, WHO hopes to hold training workshops on the control of leishmaniasis there. Although the disease exists in other parts of the world, most countries have been able to contain it. But in Afghanistan, after two decades of war, health and sanitation services have virtually come to a standstill. Leishmaniasis, "like many other public health issues, is not being addressed until it is out of control", Girardet said. Compounding the problem is the potential spread of the disease to neighbouring countries - particularly Pakistan. In the nearby Kurram Agency in Pakistan's North West Frontier Province, over 5,000 new cases have been detected in the past year alone. Another outbreak in Pakistan's southern Sind Province has affected over 9,000 people - transmitted in this case by rodents rather than humans. "This is growing too quick to ignore," Girardet said. "We could have a pandemic on our hands."