COVID-19 just the latest epidemic in areas struck by disease

SULEIMAN KHEL, Pakistan —
When Tariq Nawaz’s daughter was born a year ago, he borrowed money to pay for his wife’s cesarean delivery. Seven months later, they learned their baby had polio and sold the little bit of jewelry his wife had received for her wedding to pay mounting medical bills.

Then the new coronavirus pandemic struck Pakistan, prompting a countrywide lockdown that closed even their village of Suleiman Khel, at the edge of a tribal region plagued by militants. Still in debt, Nawaz lost his job, his monthly paycheck of $95 and the means to provide treatment for the baby’s polio.

“It’s all I can think of. I feel like my head is going crazy,” he said.

For millions of people like Nawaz who live in poor and troubled regions of the world, the novel coronavirus is only the latest epidemic. They already face a plethora of fatal and crippling infectious diseases: polio, Ebola, cholera, dengue, tuberculosis and malaria, to name a few.

The onslaught of infectious diseases is made worse by the many other threats in lives already overwhelmed by adversity. Crushing poverty leads to malnutrition and lack of medical care, making people more susceptible to illness. In many places, they must also navigate the violence of militants, gangs and government soldiers, which can make campaigns to fight disease more difficult.

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This story was produced with the support of the Pulitzer Center on Crisis Reporting.

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Just when the Democratic Republic of Congo appeared to be nearing the end of its deadly Ebola epidemic this year, the first COVID-19 cases appeared, devastating residents. Militants also terrorize the region.

“People here have been victims of attacks by Ugandan … rebels, Ebola and now COVID-19,” said 46-year-old Philémon Tsongo, a physician who survived Ebola at the epicenter of the outbreak in Beni. “They are traumatized.”

In war-torn Yemen, the cholera epidemic peaked with more than a million infections in 2017. Health officials have seen a dramatic drop in cholera, but there is growing concern that the fight against the recently arrived coronavirus will undercut the anti-cholera campaign.

Officials from the U.N. children’s agency, UNICEF, say stocks of hygiene kits and chlorine tablets for water purification in Yemen will last only until the end of June. The agency needs at least $18 million through the end of the year to buy more supplies for water, sanitation and hygiene services, but it appears the money will go to fight COVID-19.

“We think that the risk remains high and that cholera and acute watery diarrhea cases could easily make a strong, strong comeback,” said Bismarck Swangin, a UNICEF spokesman in Yemen.

Across the world in Central America, Honduras has seen a steep climb in COVID-19 cases in the midst of a dengue fever outbreak. San Pedro Sula, the business capital where gang violence makes Honduras one of the deadliest countries in the world, is also now the epicenter of a COVID-19 outbreak. The city and surrounding area have about two-thirds of Honduras’ approximately 3,000 confirmed cases.

“We have a full-blown dengue epidemic, meaning we have two illnesses circulating in the country,” said Dr. Carlos Umaña, president of the Social Security Doctors’ Association for northwest Honduras, who is based in San Pedro Sula.

The simultaneous epidemics are overwhelming a public health system that had few resources to begin with. For a population of about 10 million people, Honduras only has 350 intensive care beds and about 6,000 hospital beds overall — compared to some 23,000 in New York City.

“The collapse of the health systems are imminent if these two illnesses continue rising,” Umaña said.

In Pakistan, where Nawaz lives, coronavirus cases are going up sharply. The country’s toll of above 113,000 coronavirus cases surpasses that of neighboring China, and 2,255 people in Pakistan have already died.

Meanwhile, Pakistan continues to suffer some of the world’s worst outbreaks of infectious diseases. It has 4.3 million cases of malaria annually, and is one of the top 10 countries for new cases of tuberculosis each year. It is also one of only three countries, including Afghanistan and Nigeria, where polio is still endemic.

The fight against disease is made harder by militants who oppose vaccination. The militants in Pakistan have multiple and sometimes overlapping motives, focusing on the government, religious minorities, connections with anti-U.S. organizations in neighboring Afghanistan and attacks on Pakistan’s historic rival, India.

Militants have spread rumors that the polio vaccine is a Western conspiracy to make the next generation of Muslims infertile. Dozens of vaccinators, with heavily armed security at their side, have been targeted and killed in recent years. Just last month, a half-hour drive from Nawaz's home, masked gunmen shot and killed 40-year-old Abdul Wahab, a well-known vaccinator in the tribal regions.

Nawaz’s daughter, Tuba, was vaccinated against polio at four months, but before she could receive her second of three doses, she contracted the disease.

Dr. Rana Mohammad Safdar, the country’s leading immunologist and front-line warrior in Pakistan’s COVID-19 battle, said that last year’s testing revealed the polio virus was everywhere in the country. Now, the arrival of the coronavirus means 40 million children won’t get their polio vaccination this month, Safdar said, leaving them without protection.

Late last year, Safdar had begun to hope polio could be beaten in Pakistan. He had a battle plan and everyone on board, even reluctant religious leaders. But when the coronavirus struck, Safdar ordered his army of more than 250,000 vaccinators to shelter in their homes for their own safety and to prevent a COVID-19-infected vaccinator from spreading the virus to an entire village. He worried that just one COVID-19 infection would be grist for the militant clerics’ rumor mills.

The virus already has devoured most of Pakistan’s budget to fight the other diseases. There’s no money left to disinfect the countless fertile grounds for mosquitoes that carry crippling diseases such as dengue or malaria.

“COVID has been a devastating blow to our efforts … We are now in a position where we can’t do much,” said Safdar, who went into self-imposed quarantine after a staff member tested positive for COVID-19.

So far this year, 40 children have tested positive for polio, including Nawaz’s daughter Tuba. Safdar fears new infections this year could surpass 150, a startling figure for a disease the WHO had hoped would have been eradicated by now.

The covonavirus and the lockdown to fight it are also making worse endemic poverty. Nearly 30% of Pakistanis live below the poverty line, earning less than $2 a day.

Nawaz’s debts have been piling up. He already had sold his share of the family plot to his elder brother for money to cover his wedding and construction of his family’s one-room house.

He and three of his brothers also carry the burden of another brother who spends most of his days and nights in a drug-induced stupor. That brother, Gul, couldn’t get work and found an escape in opium, and now the extended family must care for his five children. Another brother also is broke, after losing his job as a security guard to the virus lockdown, and is trying unsuccessfully to migrate to Malaysia for work.

Sitting in the brutal heat on a steel-framed bed made of knotted rope, Nawaz held his daughter close. He thinks she feels protected in his arms.

She is his joy and his greatest worry. Tuba doesn’t talk yet. That afternoon, her round brown eyes were outlined with a thick coal and her tattered shirt was caked with dirt. Tuba can’t stand, and when Nawaz touched her right leg she pulled away. Polio has left her leg and foot lifeless, but also painful.

Tuba’s 3-year-old sister Ilana snuggled up against her father, shoving and poking at her many barefoot cousins who crowded the dirt courtyard. Social distancing has no place in their crowded world, nor in the dusty streets where women in burqas sell second-hand goods and small shops remain open despite the lockdown.

When Tuba became sick, Nawaz took her to the village clinic, but they couldn’t help and sent her home. After two visits to government hospitals, he took her to a private clinic where finally she was diagnosed with polio.

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“We didn’t know what to do. They gave her medicine, but there was no therapy, just medicines,” he said.

Since being laid off there’s no money to buy Tuba medicine or even the milk she needs to keep her other limbs strong. Instead, Nawaz says, he gives her tea with a little milk.

In late February she fell ill, but the virus had shut the government hospitals and Nawaz had to take her to a private hospital again that cost 8,800 ($50) a night. Tuba was there for four nights.

“We had no choice, she needed treatment,” he said. “There was everything for her there. … She was doing so well.”

They were told to return after three months but he knew they wouldn’t. There is no money to treat the polio.

Now they can all just pray that the family is not struck with the coronavirus. A COVID-19 patient is more likely to die in Khyber Pukhtunkhwa province, where Nawaz lives, than anywhere else in Pakistan, with a death rate of 4.6%, compared to 2.3% nationwide.

“It’s a scary place to be,” he said.

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Associated Press writers Haruna Umar in Maiduguri, Nigeria; Al-Hadji Kudra Maliro in Beni, Congo; Christopher Sherman in Mexico City and Riaz Khan in Peshawar, Pakistan, contributed to this report.