Acute watery diarrhoea - the Saleem Khan family's tale
Multan, Pakistan - One evening in late October, several relatives from Saleem Khan's sprawling nomadic family pulled him from a rickshaw and hauled him into the district headquarters hospital in Bhakkar. “Saleem arrived semi- conscious and very dehydrated. He had hardly any pulse” recalled hospital staff.
Saleem was immediately admitted to the hospital’s diarrhoea treatment centre (DTC) set up by WHO and Health Cluster partners in the aftermath of the floods. The DTC promptly notified the health authorities and WHO's operational hub in Multan that a patient had been admitted with acute watery diarrhoea (AWD) and severe dehydration. WHO deployed Dr Muhammad Tayyab, the Disease Early Warning System (DEWS) surveillance officer in the district, to evaluate the case. Dr Tayyab suspected that Saleem might have cholera. He sent a stool sample to the National Health Institute (NHI) for analysis and called in an environmental health officer to investigate Saleem’s living conditions.
The objective of DEWS is to identify and respond to any communicable disease alert immediately, in order to prevent further spread of the disease. Early detection and early response are fundamental. “Whenever we get a disease alert, either in Islamabad or at hub level, we immediately send a surveillance officer to investigate and respond,” says Dr Rana Kakar, head of the DEWS team. “For AWD, which is mainly spread through contaminated water, we send an environmental health officer and a surveillance officer to the patient's village to check water sources and investigate the history of the patient and their family. Our staff normally send us a report of their findings within 24 hours.”
Saleem's family took him home the next day, as they were on the move again and they felt his condition had improved. Thankfully, the hospital had recorded a cell phone number that the surveillance team used to track down his family of nomads. "When we arrived at Saleem's camp we found out that two members of his family, including his mother and niece, had died from AWD the previous week and that another four people were ill with diarrhoea” says Dr. Tayyab. “We were very concerned both for Saleem's family and for the other communities they will come into contact with during their journey”.
Saleem's tribe, the Salman Khel, move between the mountains of Waziristan and the plains of District Bhakkar throughout the year. In mid-October, while on the plains, Saleem's mother fell ill with severe diarrhoea and was admitted to Civil Hospital Dera Ismail Khan. Three days later she was discharged and brought home, where she immediately fell ill again. The family rushed her to a private hospital, where she died a few days later. Saleem's two-year old niece died less than 24 hours after she started having diarrhoea. “My mother got sick because the water we drank was very contaminated. It smelled very bad, but we had no other water” explained
Saleem's elder brother. “We travel more than 300 km from the mountains to the plains and drink any water we find on the way. Most of the time, it is surface water, and we and our animals drink the same water. Sometimes we drink stagnant, bad-smelling water that even our animals will not drink.”
“The family was completely unaware of the importance of personal hygiene and proper sanitation and solid waste management” says Irfan Ullah Khan, an environmental health officer. “They defecated in the open and drank any water that was available, regardless of whether it was contaminated."
The DEWS team taught the family basic health and hygiene measures to prevent diarrhoea during a two- hour session involving the men. Together, they analysed the family's hygiene practices, stressed the importance of proper sanitation in preventing diarrhoea, and discussed different ways of treating water to make it safe for drinking. At the end of the session, the team gave the family bath soap, garbage bags, oral rehydration salts and mineral water, and promised to come back with aqua tabs, water filters, jerry cans, multipurpose soap and buckets with taps.
Two days later the team visited Saleem's family again, and were pleased to see a radical change in their hygiene habits. The family had begun drinking boiled water and were washing their hands after defecating and before eating food. A second health education session was held, this time involving female family members. "I wish I had known the importance of clean drinking water and proper sanitation before. It could have saved my mother's life” said Saleem.
The keen interest shown by Saleem's family is an indication that people do want to change their behaviours, provided they are approached and taught in an appropriate manner. WHO will remain in close contact with the family and continue to assess health and hygiene changes in their behaviour. Monitoring of this particular family will help WHO develop more a systematic approach to working with the nomadic population and helping them improve their hygiene and sanitation practices. “There are hundreds of families that, like the Khan, are living in conditions that put them at high risk of AWD and other diseases.” Says Dr Guido Sabatinelli, WHO Representative in Pakistan, “these tribes travel throughout the year and could become possible unaware carriers of different diseases: raising awareness amongst them in preventative practices can not only help protect their lives, but also the lives of others”.