Bad blood in Egypt

In one of the great medical tragedies in modern history, well-meaning Egyptian authorities are believed to have infected millions of people with hepatitis C.

By Dawn MacKeen

Jun 2, 2003 | Swaddled between two arms of the river Nile, the delta is a place where everything seems to grow. Sunflowers line roads; shallots, bulbs as big as fists, sprout from the soil. Miles and miles of canals feed thick blankets of green.

Only a few hours north of Cairo, El Tod sits off a road that shifts from dust and sand to lush patches of vegetation. Camels stand tied to posts near produce carts and butcher shops where suspended animal carcasses hang outside like potted plants. News in this village is still passed from neighbor to neighbor -- and the people in each story are usually known to all.

"Are you looking for the El Sayeed family?" asks a man walking beside my car, which has slowed to a crawl. He leads me down a garbage-strewn alleyway, past kids playing, to the El Sayeeds' modest apartment. A steady wail signals sundown -- a time to pray.

On this particular evening, most of the El Sayeed family is crowded into one room waiting for me. Hamdy, the father, is present only in a framed picture on the wall. The 50-year-old man lies in a hospital bed on the outskirts of Cairo. His neighbors know why he isn't at home. They also know why Hamdy's cousin doesn't show up at his clothing store on some days -- probably feeling too weak -- and why yet another cousin, Hamed Zayed, stayed in El Tod instead of moving to Saudi Arabia as he had planned. The reason? Zayed did not pass the blood test required to work in Saudi Arabia. Like those of many others in town, his came back positive.

The disease infecting the El Sayeeds isn't AIDS. Their medical records tell the story of another blood-borne pathogen -- the hepatitis C virus (HCV) -- which has its grip on this region and 130 million to 170 million people worldwide. The virus is spread mainly by blood; everything from intravenous drug use to tattooing and body piercing is a common vehicle for transmission. Globally, HCV is three to four times as prevalent as HIV, and there is no vaccine to prevent it. Yet, perhaps because it is a benign companion for the majority of carriers, HCV has not received a great deal of attention as a major public health issue.

The number of people worldwide with this highly contagious virus will continue to climb until 2015 to 2035, according to estimates from the World Health Organization. And many cases have fatal consequences. In the United States, 8,000 to 10,000 victims of HCV die each year, and the number of Americans who are waiting for a liver transplant has increased almost sixfold over the last decade, according to the United Network for Organ Sharing. Unless organ donations increase drastically, the organization's officials warn, there won't be enough livers to go around when they are desperately needed. There aren't enough even now.

"Hepatitis C still doesn't have the pizazz of AIDS. It doesn't drive countries to do something," says Harvey J. Alter, chief of the infectious-disease section at the National Institutes of Health. "But in point of fact, it's a huge global problem."

Egypt, with 12 to 15 percent of its population estimated to carry the virus's antibodies, hovers near the top of the global HCV chart. (In the United States the percentage is 1.8.) The El Sayeeds live in a region that lies at ground zero in the HCV crisis. Studies of villages in the Nile Delta show that about half of the residents older than 35 have the virus or have had it in the past.

"We heard about it two years ago," explains Hamdy's brother, Moawed El Sayeed. "We heard about it but didn't see no one sick of it. Now many, many have hepatitis -- I feel that if I do the test, most likely it's positive."

The viral time bomb is set to go off in Egypt -- and the United States -- in the next few years. And yet most people who are chronic carriers do not know they have it. In some cases, people in Egypt know they are ill but aren't able to distinguish the virus they carry from the other alphabet of hepatitises -- A, B, D and E.

Making matters worse are the prohibitive cost and limited effectiveness of treatment with the latest antivirals. In a dilemma similar to that caused by HIV, it is not possible in Egypt to provide the drugs to all who need them. A further complication is that liver transplants are basically not an option here. Procuring livers from the dead is culturally taboo in Egypt.

The country's burden -- in the sheer number of victims and the hurdles to treatment -- makes Egypt a worst-case scenario worthy of global attention. Indeed, Egypt is a laboratory for the world's HCV researchers: Epidemiologists are monitoring the largest group of patients here as they approach the time -- decades after infection -- when malignancies such as cirrhosis or liver cancer tend to occur.

But Egypt's tragedy also has a unique aspect that other countries are unlikely to encounter: The virus is believed to have been spread here, unintentionally, through improperly sterilized syringes used by government health workers to treat millions for bilharzia, a debilitating illness that was sickening farmers and others who lived around the Nile. The government medical campaign, now thought to be largely responsible for the HCV epidemic, took place before hepatitis C was identified. Epidemiologists now contend that it may be the medical community's largest transmission of a blood-borne pathogen in history.

Any outrage over the fact that this country's misfortune can be attributed, in large part, to the actions of its government, has been largely absent among its citizens, most of whom see their plight as the will of Allah. And talking about the campaign against bilharzia, and its disastrous impact, makes Egyptian officials extremely uncomfortable; even those doctors researching the issue admit there's a problem, but they play down any grave ramifications. The "healthy" are routinely pointed out to visitors; the "ill" are barely acknowledged. Liver specialists say they have been fearful of speaking out for fear of losing their jobs or seeing their programs eviscerated.

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