KARACHI, Pakistan — Haleema first thought the rash on her daughter’s skin was heat related. It was mid-May, and with temperatures in Karachi had been soaring over 100 degrees, electricity was sporadic.
But two days later — after Shaista, her daughter, stopped eating and began running a mild fever — her neighbor urged Haleema to take her to the hospital.
“It’s measles,” the neighbor told Haleema, shaking her head after finding white spots on Shaista’s tongue. Haleema had never heard of it.
In the last four months, more than 20,000 cases of measles, a highly contagious respiratory virus, have been reported across Pakistan, where inoculation rates are among the world’s worst. With less than 50 percent of the country vaccinated, more than 100 people have died from measles in Pakistan this year, according to Pakistan’s Ministry of Information.
Large budget cuts in international funding for vaccine initiatives, attacks on female health workers in conservative areas, and the lack of a national healthcare system in Pakistan are all contributing to a measles epidemic that leaves children particularly vulnerable.
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“Most of the children who come into the hospital with measles are also extremely malnourished and dehydrated,” said Dr. Ali Faisal Saleem, a pediatrician at Pakistan’s Agha Khan University Hospital in Karachi, the country’s largest city. “They’re operating on an already compromised immune system.”
Measles, which grows in the cells that line the back of the throat and lungs and causes a rash like Shaista's, has no cure.
In most developed countries, vaccines against the virus are mandatory and almost all children are immunized. But according to the US government’s Center for Disease Control, measles kills more than 100,000 children around the world each year — almost half of which are in Pakistan's neighbor, India.
Doctors and health officials here say Pakistan’s fresh epidemic is a result of a disorganized and decentralized healthcare system stymied by corruption.
In 2011, Pakistan dissolved its national health ministry, relegating health services to underfunded and thinly staffed provincial governments.
These local governments in a country of 187 million are tasked with carrying out the country’s vaccination campaigns for children between one and five years old in affected areas.
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But because international funding for vaccination initiatives in the developing world has recently been slashed, many of the country’s children are falling through the cracks. According to the United Nations Development Fund, 103 million Pakistanis are under the age of 25.
The Measles and Rubella initiative — a partnership between the American Red Cross, the US Centers for Disease Control and Prevention, UNICEF, WHO and the UN Foundation — is facing a shortfall of $171 million for their planned vaccination campaigns worldwide over the next three years, according to a report from the American Red Cross.
The GAVI Alliance, a US-based vaccination initiative affiliated with the Bill and Linda Gates Foundation, pledged $35 million to fund immunization efforts in Pakistan for 2013.
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But according to reports in Pakistan’s Express Tribune, a local English-language daily affiliated with the International Herald Tribune, the GAVI Alliance has deferred payments to Pakistan until the government draws up a concrete plan to immunize its at-risk children.
The same reports, which are based on official documents reportedly leaked to the newspaper, say Pakistan needs about $65 million to execute an adequate measles vaccination program.
In the meantime, cramped and unsanitary conditions in both urban and rural areas mean the virus — which is transmitted through the air by breathing, coughing, and sneezing — can spread even faster.
In Karachi, roughly 21 million people live in one of the most densely populated cities in the world, at 15,000 people per square mile. Because measles has an incubation period of about 10 days, many people who have already contracted the disease show no symptoms. They unknowingly passing on the virus without ever feeling ill, doctors say.
“If you aren’t vaccinated, and I have measles, and I sneeze on you, 90 percent of the time, you’ll get measles too,” Saleem said.
Saudi Arabia is even considering a ban on Pakistani nationals attending this year’s Hajj, an annual Muslim pilgrimage to Mecca, local press reports in Pakistan say. About 3 million Muslims from the around the world travel to the holy city each year, often sharing close spaces with each other.
“If one person in that house has the virus, the likelihood that any one else in that house has been vaccinated is slim,” Saleem said. “And these are houses with more than seven people living in them.”
Compounding the problem further is a recent spate of attacks against female health workers, both in Karachi and elsewhere in the country, and which has hindered larger vaccination campaigns, initially for polio but also for measles.
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The Taliban, who hold sway in the wide swathes of land on the Afghan border, have prohibited polio vaccinations following the revelation a Pakistani doctor was using a vaccination drive to help the CIA locate Osama bin Laden.
Haleema and Shaista were lucky, however.
By the time Haleema had carried Shaista into Karachi Civil Hospital, one of the city’s government-funded facilities, her daughter was running a fever of 104 degrees. A nurse wearing clean, starched scrubs hooked Shaista with a fever of 104 degrees, up to a banana bag, a bag of IV fluids filled with electrolytes and minerals that would help rehydrate her.
Shaista’s fever eventually broke.
The nurse explained to Haleema that she should watch other children in the neighborhood for potential symptoms.
“The trickiest part is when a mother will bring one of her children into the hospital,” said Dr. Faryal Mustafa, a pediatric resident in Sukkur, which is located about 500 km away from Karachi, one of the hardest hit areas in Pakistan. “We know that she probably has at least three other children at home, and that most likely none of them have been vaccinated.”