PESHAWAR, 17 July 2007 (IRIN) - Shandana Khan's curly brown hair spreads across her pillow as she sleeps in her family's cramped two-room house in the Saddar area of Peshawar, the capital of Pakistan's North West Frontier Province (NWFP).

The five-year-old's grey-green eyes flicker briefly as she awakens, and sitting up, almost unconsciously she runs her fingers across the distinct, purple-black welt that runs across her left hand. Her younger sister, Faiqa, playing under the string bed, has a similar mark on her forehead.

"It is a terrible misfortune. If these marks do not go away, no one will marry my daughters," remarked Aziza Bibi, 30, the mother of the two girls and an infant son whom she holds in her lap.

In the traditional Pashtun way of life that still determines the way in which most people in the NWFP lead their lives, marriage is crucial to the future and the welfare of girls: Any scar that mars physical beauty acts as a huge barrier to the arrangement of a successful match.

Shandana and Faiqa's family have never heard of leishmaniasis, a skin disease caused by the bite of the sandfly. While the disease, in its most common form, is completely curable and does not threaten life, left untreated it can cause permanent scars and brings with it considerable stigma, with persons afflicted by it quite often ostracised for fear that the disease may be caught from them.

"Shandana has not been to school for two weeks now because she says the other children refuse to play with her," said Aziza Bibi.

While leishmaniasis is endemic in parts of Pakistan, including the NWFP, the southwestern province of Balochistan and parts of southern Sindh Province, illiteracy and a limited health network mean there is almost no awareness about the disease, its causes or ways to prevent it.

"Although leishmaniasis has been here now for many years, many victims have no idea that it can be treated. Since it is closely linked to unhygienic living conditions and poverty, it would take quite wide-ranging reform to eradicate it," said Faisal Saeed, a dermatologist working at a charitable clinic in Peshawar.

Sandfly

Sandfly is a tiny parasite that lives in nooks and crannies within homes. The minute size of the insect means it can crawl in through the mesh of most kinds of mosquito netting, rendering this commonly used preventive measure against bites ineffective.

Exposed areas of the body, including the face, arms and hands are most often bitten.

The sandfly-borne disease is transmitted when an infected person is bitten and the parasite then bites an uninfected person. The bite usually causes a small pimple, which grows with time to become an ugly lesion. The lesions most often heal over by themselves within months, but left untreated, can cause scars to be left behind. More rarely, the disease can affect internal organs and prove fatal.

According to the World Health Organization (WHO), at least 1.5 million people, almost all of them living in developing countries, are afflicted by the disease.

Pakistan's first encounters with leishmaniasis began in the late 1990s, when the disease spread mainly in the NWFP. It was believed to have first taken root in Afghan refugee camps, to which it came from across the border.

Since then, the disease has spread rapidly with thousands affected by it over the years. Precise numbers are difficult to estimate as it is believed many cases go unreported.

In 2002, the WHO stated at least 700 cases had been reported in the NWFP alone, most of them in children under the age of 15 years.

Efforts to control the disease

Supplies of the injectable drug glucantime, used to treat the disease were flown in and aerial spraying measures initiated - but these proved insufficient to control the disease.

In 2005, large-scale outbreaks of the disease were reported from Pakistan's Sindh and Balochistan provinces, with 1,200 cases reported from Sindh alone. Outbreaks were also reported from many parts of Balochistan Province.

Hadi Bux Jatoi, the Sindh director-general of health services, said the disease was now under "greater control than before" though cases were still reported in the province. He said the situation continued to be "monitored".

In the NWFP, in March this year, according to newspaper reports, thousands of new cases of the disease were reported, with at least 3,000 patients treated by the WHO or other health agencies. Health department sources said the failure to purchase anti-leishmaniasis drugs for government hospitals was adding to the difficulties.

A spokesman for the NWFP health department, however, emphasized: "Early problems have been overcome." He linked the spread of the disease to a current epidemic, which is sweeping across Afghanistan, and has spread from there to neighbouring parts of Pakistan.

Despite stepped up preventive measures taken by the Pakistani government since 2000, including attempts to eradicate the sandfly by spraying and encouraging the use of mosquito nets impregnated with insecticide, leishmaniasis outbreaks continue to flare up across the country.

People like Aziza Bibi maintain it is "not easy" for them to reach doctors, or pay the approximate US$30 that a course of treatment costs, and as such the poverty and illiteracy prevalent in the country means the disease has not yet released its grip over people across Pakistan.

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