In the northwest corner of Afghanistan, bordering Iran and Turkmenistan, sits the district of Gulran, where in 1974 an epidemic of liver disease struck the poorest families in several district villages. More than 20% of these villagers displayed clinical signs of liver toxicity, and the Afghan authorities determined the etiology as bread whose wheat was contaminated with the seeds of the charmac plant (Heliotropium). Charmac is a weed inadvertently harvested with the wheat, and the seeds contain pyrrolizidine alkaloids that inflict severe liver injury. The toxicity leads to a progressive, massive abdominal distention from fluid accumulation in the gut (ascites) as the liver degenerates over several months in a process somewhat similar to accelerated alcoholic cirrhosis.
Some villages in Gulran are suffering another epidemic of liver toxicity. New, dramatic cases of ascites began in November, 2007, again among some of Gulran’s most impoverished families. Many if not all of the victims are chronically malnourished and subsist on a diet of wheat bread that is occasionally supplemented with meat. (Very few fruits or vegetables grow in Gulran.) The cruel irony is that the little food these villagers have available might be killing them.
Health authorities transported several patients with severe disease to Indira Ghandi Hospital in Kabul for treatment. I visited these patients yesterday, and the first I saw were a pair of young siblings whose parents had both died recently from the disease. The next patient was a twelve year-old girl in such an advanced stage of illness that I would be surprised if she is still alive. She had a gaunt, weathered face that was absolutely skeletal, and I thought of the terrible newsreel footage depicting concentration camp victims liberated at the end of World War II. She looked ghastly. Thankfully, blankets covered her massive belly. Her limbs were so emaciated that the skin outlined the contour of her bones.
Initially I wanted to take a photograph of her, but I changed my mind quickly as I thought the attempt would be crass and vulgarly voyeuristic. Instead, I recalled another twelve year-old girl in Kenya whom I watched literally drown to death in a hospital bed over the course of a week due to congestive heart failure. Rheumatic heart disease had shredded her cardiac valves, and the damage had reduced her heart’s pumping capacity so much that blood collected in her lungs and saturated the pulmonary tissue, and eventually the mitigated oxygen exchange couldn’t sustain her. $5 worth of penicillin earlier in her life when she had a case of strep throat might prevented the cardiac disease. At least the Afghan girl had a bed of her own, as the Kenyan patients slept two-to-a-single-bed laying opposite directions on the mattress. If the Kenyan staff expected you to die within the next few hours, they would move your bedmate and place a screen around you, an effort that gave a bit of privacy in a crowded open ward and left the other patients less unnerved.
I haven’t cried over a sick patient since medical school, but I felt my eyes moisten when I saw that dying Afghan girl and the new orphans across the ward from her. The worst of the world’s cruelty seems reserved for the poor, young and defenseless. These children come from an agriculturally barren district, likely have a genetic predisposition for liver failure and suffered malnutrition before they even ate the contaminated wheat. Two of them were treated for tuberculosis the previous year. They are getting delayed but appropriate supportive care now in the Kabul, but they are so sick that they may die alone in the hospital away from any family members who have survived this latest epidemic. Mickey Mantle inexplicably popped to the top of the liver transplant list after years of pickling himself with booze, then he died only a few weeks later and took that precious donated organ into the ground with him. These kids have no prospects for such advanced medical treatment.
The two children in the photographs above are medically stable and the physicians think they might survive the liver toxicity. They still have dramatic abdominal swelling due to ascites. The boy seemed obtunded when we spoke with him. The girl was stationary but playful (look closely at the photograph and you can see that she is all belly under her dress), although at first afraid of a toy we gave her. In fact, all of the children were initially frightened by the stuffed animals we offered them, and one of the physicians told me they probably had never seen such a toy before.