A pediatric outbreak in a remote Pakistan city shows the urgency of global health after Covid.
One day in February 2019, Nazeer Shah carried his 1-year-old daughter, Eman, into a medical clinic. The doctor there, Imran Arbani, was immediately alarmed: The girl was limp and lethargic, her head flopped over on her father’s shoulder. Her breathing was shallow and fast. She was asleep, hard to rouse, except when she woke to cough. She drooled from her mouth. Her tongue was covered with a thick white coating, which Arbani recognized as thrush, a condition that usually indicates a weakened immune system. At around 11 pounds, she was frighteningly underweight.
Shah told the doctor that Eman was born healthy and was well until three months earlier, when she began having diarrhea daily. Her weight dropped precipitously; she spiked fevers regularly. Every day she seemed worse than the day before. Shah handed the doctor a green plastic bag filled with assorted syrups and pills — more than a dozen different medications. These were all the things she had tried, he explained. Nothing helped. He had taken her to several doctors here in Ratodero, an impoverished city in southeastern Pakistan, and to specialists in Larkana, a city roughly 20 miles to the south. He couldn’t get any clear answers.
Shah lives close to Arbani’s clinic but was initially hesitant to take Eman to him because his specialty was urology. Arbani, however, is used to practicing family medicine as well. “A doctor is a doctor,” he says. “The people do not treat doctors who are specialists as specialists. I deal with a lot of general problems too.” Arbani, who has thick, expressive eyebrows and speaks in quick, forceful clips, told Shah that he wanted to test the girl for the human immunodeficiency virus.
“Doctor, are you joking, saying she might have H.I.V.?” Shah replied. “How is it possible?” But it was seemingly the only test that had not been done yet, so Shah drove Eman on his motorbike to a local laboratory, where a health care worker pricked her finger for a drop of blood. They waited outside for half an hour, until Shah was given a slip of paper. “Weak positive,” it read.
“I was still confident at that point,” Shah told me. “It could be negative.” He took the results to Arbani, who suggested that Shah send another test to a satellite lab in Larkana run by Aga Khan University Hospital in Karachi, one of the country’s premier academic medical centers. Afterward, Shah returned to Arbani’s clinic so that together they could look at the results, which were available online. When they saw the word “reactive,” Shah began to weep.
Arbani counseled him on the next steps and advised that Eman go to Karachi, more than 300 miles away, because the closest H.I.V. treatment facility, in Larkana, was set up to treat adults. Shah, who had a stable bank job at the time, was able to scrounge up the 2,400 rupees, or about $15, for his family’s bus fare. (The average household income in Pakistan is around $260 a month; most in Ratodero survive on far less.) He spoke to a close friend and told him about his daughter’s condition. The response shocked him.
“My kid already has H.I.V.,” Shah’s friend said. Eman, it turned out, was not the first young child infected with the virus in Ratodero, where more than 300,000 people live. Shah’s friend’s son received the same diagnosis two years before. In each case, the parents tested negative for H.I.V.