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Cutaneous leishmaniasis medical care in Pakistan: Patient stories from Quetta

17 Jan 2023

Cutaneous leishmaniasis is a skin infection caused by a parasite transmitted by the bite of a phlebotomine sandfly. 

Médecins Sans Frontières (MSF) treats patients with cutaneous leishmaniasis at seven specialist facilities in the cities of Quetta, Kuchlak in Balochistan and Peshawar and Bannu in Khyber Pakhtunkhw

Cutaneous leishmaniasis is a skin infection caused by a parasite transmitted by the bite of a phlebotomine sandfly. It is common in Pakistan, particularly amongst poor, both urban and rural populations in Balochistan and Khyber Paktunkhwa provinces. The disease is characterised by lesions on the face or any other part of the body which can result in disfiguring scars. It is easily treated by injections of either meglumine antimoniate or sodium stibogluconate, but these medications are not always available in health facilities, as treating the disease is not considered a public health priority in Pakistan.

MSF treats patients with cutaneous leishmaniasis at seven specialist facilities in the cities of Quetta, Kuchlak in Balochistan and Peshawar and Bannu in Khyber Pakhtunkhwa, providing them with safe and effective treatment and our teams in Balochistan also provide mental health support for the cutaneous leishmaniasis patients. MSF teams also increase awareness in local communities about how to prevent and treat the disease.  

In 2021, MSF teams treated almost 6,159 patients with cutaneous leishmaniasis, curing 99 per cent of them.

Amina, Asma and Abdul Raheem

Two-year-old Amina lives with parents and older siblings in the Pashtunabad area of Quetta, a dry mountainous region where sandflies are common. Amina is the third member of her family to have been treated for cutaneous leishmaniasis at MSF’s clinic in the city’s Benazir Bhutto hospital.

Cutaneous leishmaniasis is a skin disease spread by the bite of the phlebotomine sandfly.

Amina has a large lesion on her right cheek that has become infected. “Amina got the lesion around seven months ago,” says MSF nurse care provider Beenish Ramkishan. “It’s currently five cm wide with a crust and pus. They have to visit daily for cleaning and treatment.” 

Amina’s parents, Raheem and Noori, make carpets and homemade decorations, which her father sells in the capital, Islamabad. They struggle to afford the 30-minute motorcycle trip to bring their daughter to the clinic each day, but see it as a priority. “It is hard to come on the bike, but it is also important and compulsory to come because of our daughter’s treatment,” says Raheem. “We do not want to take a risk by missing it.”

The family’s visits to the clinic have been going on for many months, as first Raheem and then three-year-old Asma were treated for the disease. 

“I also had two lesions last year and I got them treated at this clinic,” says Raheem. “The lesions were cured and I have a scar now, but I’m not worried about them.” The other daughter of Raheem, Asma was diagnosed with cutaneous leishmaniasis in March 2021. “Asma had a red spot on her face and over time it grew bigger,” remembers Raheem. He was told she would have to wait a month to start treatment at MSF’s busy clinic.

Keen for her to start treatment straight away, they went to a private clinic. “I had to buy the injections myself, which were expensive and often not available, but we managed it for our daughter’s sake,” says Raheem. But the treatment was ineffective and the lesion increased in size. “After six weeks of treatment there was still no effect on the lesion – instead of being cured, it had grown bigger,” says her father. “Thankfully, we received a call from MSF’s clinic. We rushed her here and she started treatment in March.”

Asma has recovered from the disease. “The lesion was cured in April, but it left a deep scar,” says her father. “We are worried about it, as it covers one side of her face, but there should be treatment to fix it.” 

Untreated or wrongly treated cutaneous leishmaniasis can cause severe disfigurement, leading to stigmatisation by the community.

For unmarried girls, the stigma around facial scars can make it difficult for them to find a marriage partner. The only way to treat the scar is to opt for plastic surgery which is also very expensive and not always available in rural areas or small cities.

Amina’s treatment will continue for 20 to 28 days, depending on how the lesion responds. Each day, she receives injections of meglumine antimoniate, after which the infected lesion is cleaned and a new dressing applied. 

“I myself received treatment in this centre and many people in our neighbourhood have been cured here, so my daughter will also be cured,” says Raheem.

Muhammad Idrees

Muhammad Idrees, aged 10 years, is in the fifth grade at school. He lives with his family in Pashtunabad, Quetta, where his father, Hafiz Abdul Rasheed, works as a labourer. Idrees has two lesions of cutaneous leishmaniasis. In the past two years Idress was using different home remedies which made the lesions worse. 

“The lesions on Idrees’ nose had turned into crust and pus with a secondary infection, but the lesion on his left leg was not as big. After two years he came to the MSF clinic and was diagnosed with cutaneous leishmaniasis and later the treatment was started,” says MSF nurse care provider Beenish Ramkishan. “We give him injections of meglumine antimoniate.” 

Idrees travels 45 minutes by motorcycle from his home to the clinic each day with his elder brother, Abbas, to receive his injectable medication and have his dressings changed. Waiting outside the treatment room, Abbas says that his brother is very self-conscious about the lesion on his nose. “The lesion on his nose is big and he wears a cloth facemask whenever he goes out so that it is not visible,” says Abbas. “He is shy at times because of how it appears.”

Idrees has stopped attending school after the lesion drew the unwelcome attention of his classmates. “The lesion on my nose has got worse and it doesn’t look good to me,” he says. “Fellow students at school also ask me questions.” Classmates teased and bullied him about the lesion, try to punch him on the nose. It got so bad that Idrees decided to stay at home. “I have stopped going to school but I will return to school once my lesion has healed,” he says. 

Idrees says he is upset not to be at school, and thinks about it a lot, but has found other ways to spend his time, such as playing football, playing games on a mobile phone and revising his school work.
His family are very supportive. Idrees’ mother says: “He has decided to not go to school until the lesion is healed, and we support his decision. He’s a good boy and takes care of his work. He also helps me at home with the chores.”

Idrees is on day four of his 20 to 28 days course of injections and feels optimistic that the end is in sight. “I felt stressed when I first saw myself in the mirror,” he says, “but thankfully my treatment has started and now I don’t feel as worried. I am hopeful that this lesion will heal soon and I will be able to go back to school. I want to do everything I can for my mother and make her wishes come true.”