Filariasis: An Endemic Infectious Disease in India

In India, patients present with diseases on a daily basis that we only read about in the United States: scrub typhus, typhoid fever, leprosy and malaria to name a few. Therefore, the physicians training and treating this patient population learn to build many of their differential diagnoses around disease presentations, which would be considered very obscure by American physicians. I learned this lesson very quickly in the outpatient clinic during my week on CHAD (the community health rotation). One day, when I was working with a young Indian physician, a man came in for interpretation of blood work. He reported having a fever for the past couple weeks along with fatigue. He had also noted painful swellings in his groin region (painful, swollen lymph nodes). Consequently, he had come to the clinic for further workup. The patient’s blood work showed evidence of anemia as well as a significant increase in eosinophils. The doctor informed me that this patient’s increase in blood eosinophils most likely indicated a parasitic infection, specifically filariasis. Although I have often read that eosinophilia may indicate a parasitic infection, parasites are not usually the first consideration in such circumstances and it certainly wasn’t on my differential diagnosis list. In the end, we treated the patient for filariasis with a combination of Albendazole and Ivermectin. The intern informed me that liberally treating suspected filariasis without using diagnostic test to confirm the etiology is an extremely common practice in India, since filarial diseases are so prevalent and are very commonly seen.

Filariasis is a disease with very few acute symptoms that develops and festers over many years and can ultimately leads to elephantitis (enlargement of the limbs and genitalia secondary to lymphatic obstruction). There are actually three manifestations of filariasis that can develop in humans, depending on what area of the body the worm occupies: lymphatic filariasis, the most commonly seen manifestation that causes elephantitis, subcutaneous filariasis and serous cavity filariasis. It is lymphatic filariasis that presents the main global challenge, as it has currently infected an estimated 120 million people worldwide, with over 1/3 of those cases resulting in serious disability and disfigurement. Furthermore, India, with its dense populations and booming cities, harbors a huge percentage of the global burden of the disease (more than 40%). One study done in India estimated that a minimum of $850 million dollars is lost every year resulting from a combination of treatment cost and missed working days.

Filariasis is caused by a thread-like filarial nematode worm. There are nine different nematode worms capable of causing the disease. The most common disease-causing nematode seen in India is known as Wuchereria bancrofti. These nematodes infect humans via mosquito bites. When an infected mosquito bites its host, it deposits microfilariae into the skin. These larvae travel through the dermis and ultimately gain access to the lymphatic system. They then take up residence in the lymphatics and the larvae mature into adults over the course of almost a year. These adult nematodes can then survive for up to five years in the lymphatic system, during which time they mate and produce many thousands of offspring per day.

Filariasis is a silent disease that is often acquired during childhood but takes many years for disease manifestations to surface. And in fact, those infected later in life may never develop outward manifestations of the disease. However, newer studies have shown that many outwardly healthy adults infected with filarial nematodes may actually have hidden lymphatic pathology as well as kidney damage. Some patients, however, will suffer acute disease manifestations including acute adenolymphangitis, filarial fever and tropical pulmonary eosinophilia. Acute adenolymphangitis characteristically presents with painful lymphadenopathy and fever (most likely what my clinic patient was suffering from). The symptoms most likely result from immune-mediated responses to dying worms within the lymphatic system. The inflammation resolves within one to two weeks without intervention, but tends to recur frequently. Patients infected with filarial nematodes can also present with filarial fever, characterized by limited episodes of fever without obvious lymph node enlargement. This isolated febrile illness is often confused with other tropical diseases, such as malaria. Rarely, acute filariasis can also cause tropical pulmonary eosinophilia, manifested as nocturnal wheezing. The wheezing results from immune hyperresponsiveness to microfilaria in the lungs.

Chronically infected patients will show disease symptoms. Symptoms are more often seen in men than women. Long term infection will lead to chronic edema, harding of the tissues and hyperpigmentation of the skin. When the lymphodema is severe, it is referred to as elephantitis, which can be disabling as well as very disfiguring. In the rural villages around Vellore, I saw multiple advanced cases of elephantitis in people who obviously suffered from longstanding infection. Men with filariasis can also develop hydroceles (fluid filled enlargements around the testicles), which can lead to permanent genital damage. In addition to the irreversible lymphodema that develops with chronic infection, there are acute episodes of local inflammation involving skin, lymph nodes and lymphatic vessels. These acute inflammatory episodes are not a direct result of the filarial infection, but rather a result of superimposed bacterial infections of the skin secondary to damaged lymphatic channels and suppressed immune responses.

Until recently, lymphatic filariasis was difficult to diagnose in the communities where it is most prevalent. Filarial infections generally had to be detected microscopically in the blood, which was very difficult without advanced laboratory technology, not to mention very costly. A new test allows finger prick drops of blood to be used to detect circulating parasitic antigens without the need to isolate actual parasites. With this new card test, advanced laboratory technology is unnecessary and the cost is much lower. However, as my opening story illustrated, doctors working in endemic areas will often treat suspected filariasis without using a confirmatory test.

The recommended treatment for killing adult filarial worms is a combination of albendazole and ivermectin. A combination of diethylcarbamazine (DEC) and albendazole has also been shown to be effective. The primary goal of treatment in endemic areas is to interrupt the mosquito transmission cycle by eliminating microfilariae from the blood of infected patients. If patients are not treated until the disease is in the advanced stages of elephantitis, they can still benefit from anti-parasitic treatment. However, the most significant intervention in advanced stage disease is most likely prevention of superimposed bacterial and fungal superinfections, which advances the pathology and causes more suffering than the infection itself. The WHO has proposed a treatment strategy to eliminate lymphatic filariasis, which involves treating the whole population in an endemic area with once yearly albendazole plus ivermectin or DEC over the course of 4-6 years. Alternatively, the WHO has suggested fortifying common table salt used in cooking with DEC in endemic regions.

While lymphatic filariasis is usually not a life threatening disease, it exerts incredible social impact, especially on impoverished people in society. The grotesque complications resulting from longstanding infection result in social stigmatization for men and women as well as physical limitation that inhibits livelihood. Therefore, it is an important disease which is easily treatable in early stages and can be eliminated with proper education and treatment campaigns.

Sources:
Leder, Karin PhD and Peter Weller MD, FACP. "Epidemiology, pathogenesis, and clinical features of lymphatic filariasis." Ed Peter Weller. UpToDate. 1 Oct 2008. 5 Feb 2009. www.uptodate.com/online/content/topic.do?topicKey=parasite

World Health Organization. "Lymphatic Filariasis." Revised September 2000. 5 Feb 2009. www.who.int/mediacentre/factsheets/fs102.en.print.html

Winding Down: Medicine Continued

My final week on medicine has been ok, although I must admit a little more routine than I would have liked. It has been cool to experience diseases that are only read about in the US, mostly related to infectious disease. I have seen a fair amount of scrub typhus, an endemic tick-borne disease that presents with severe headache, high fevers and black eschars on the body and can often be lethal, even when the patient receives proper treatment. I have also seen a lot of tuberculosis, but the cases are much more advanced beyond pulmonary TB. On the ward, I have seen both disseminated tuberculosis and TB meningitis. These patients with extra-pulmonary TB manifestations are often quite sick and having the opportunity to see such advanced cases is very interesting and a unique privilege. However, the most beneficial part of my medicine week was probably observing the outpatient clinic yesterday, primarily because I had a chance to discuss the methods of payment and reimbusment with my resident. I have sort of been wondering about cost and how people here are able to afford such expensive procedures such as MRIs and angiograms given that most people here live in poverty. As it turns out, emergency treatment is not all that different from the US. If someone walks in to the ER with a massive myocardial infarction, for example, they will be admitted and taken care of. However, the doctors will only perform tests and procedures that are directly related to initial stabilization. So in the case of a heart attack, the patient would be admitted and stabilized, but further diagnositic work up to determine the cause of the MI, such as an angiogram, will not be performed unless the patient can pay for it. Acute emergency treatment is similar in the US, in that, regardless insurance status or ability to pay, patients will be acutely cared for. However, CMC has also set up a system to take care of patient's less acute problems. When patients come to the clinic at CMC, the doctor is supposed to assess their financial status, both by asking questions and by judging their physical appearance. If it is determined that the patient cannot pay, the medicine department will pay for most any test the patient requires, even if it is something very expensive such as a CT or MRI and they will cover doctors visits etc as well. And if the patient falls into a category where they have some money but are unable to afford an expensive test, they are encouraged to go to the Government hospitals located in the larger Indian cities, where I was told any test that is required will be covered by the government (although the waiting period may be extensive). Apparently, there are also companies that provide medical insurance, but only very wealthy people are able to afford this insurance. So for the most part, the people here get taken care of, even when they have very limited resources.

Cultural Reflections

My time in India is quickly coming to an end and I will be finished at CMC at the end of this week. During my stay, I have of course been reflecting on the Indian medical system, comparing/contrasting it with the my own experience in the United States and writing about my observations. And while the healthcare systems may share many similarities (as I have noted in my previous blogs), I find that the cultural experience between being in the US and being in India are worlds apart. I am not even sure where to start talking about this. From day one, the transition from a modern social and economic structure back in the US to a developing nation such as India is shocking and overwhelming. Before coming to India, I had visited many places, such as Mexico and Costa Rica, where there was extensive poverty and poor infrastructure, but none I have seen so far compares to India. First of all, it is just so crowded. Everywhere you go, even here in Vellore, there are people begging and pushing and staring. And I have already talked a little about the driving, which is just plain dangerous. Buses and rickshaws and motorbikes all swerving, honking and driving into oncoming traffic to avoid oxen drawn carts taking up one lane of the two lane road. Secondly, beside the people and the noise, it is very dirty. There are piles of trash everyone, animal feces littering the streets and lots of public urination. Third, the extreme poverty takes some real getting used to. In general, the standard of living is far below US standards. Even people who are employed live fairly meager existences. I was able to visit the home of both a bus driver and health aid employed by CMC. In both cases, their houses consisted of a couple small rooms plus a kitchen with cement floors and no adornments. And this is more than many people have. Beggars were exceedingly common in all of the parts of India I visited and unlike the US, there are not shelters or welfare programs that the homeless can turn to. Another interesting observation is that the public domain in India is dominated by men. When I saw women out in public, they were usually accompanied by their husbands. I rarely ever saw groups of women together in public. Most all of the shop and restaurant owners were men. Women rarely drive cars. In all my time in India, I maybe saw one or two women driving a car or motorbike. And finally, Indian people are generally very short. At 5'5", I felt like a giant in India. I was taller than most of the women and many of the men. It was nice when I was watching surgery because for once, I could just look over everyone's head.

In terms of my interactions with the locals here in India, I have had a mixed experience. On the one hand, people are always trying to take advantage of you. This is just not something that any Westerner is accustomed to. People usually want to rip me off. I am white and don't speak the local language and therefore, I am a very easy target. But on the other hand, I have met some extremely nice, welcoming and helpful people during my journeys around India, which have made me think twice about my attitude towards the people here. While on the train to Mysore one day (we were traveling from Bangalore to Mysore where the maharajah's palace is located), Stefanie and I struck up a conversation with a guy just a few years older than us on the way to visit his wife in Mysore. We got talking to him, and were able to ask him our many questions about local India culture. He helped us figure out how to navigate the local trains system and even changed his return train trip so he could make sure we arrived safely back at our hotel. I don't think I have ever had a stranger go so far out of the way for me. And this situation has repeated itself on many occasions. In sum, I think that India people can be a little rough around the edges (often pushy, very impatient etc), but are often willing to go out of their way to welcome strangers into their country.

Another interesting aspect of India culture is religion. In South India, where Vellore is located, the people are mainly either Hindi or Christian. There are a few Muslims around, but there are by far the minority. The interesting part about religion in India is how much it impacts everyday life. For example, in the Hindu faith, cows are regarded as sacred. For this reason, although not everyone here is Hindi, the cows that wander the streets of India, interfering with traffic and getting into trash piles, are totally immune from repercussion. And very very few restaurants here in Vellore serve any sort of beef dishes. Christianity also an integral part of the cultural experience here, especially in Vellore because CMC is founded on Christian principles. While there are many religiously affiliated hospitals in the US, the Christian principles are much more salient here. For example, prior to every surgery that is performed, there is an extensive prayer that is recited by the nurses and scrub techs. Bible readings and Christian symbols decorate the walls of almost every hospital ward and office. The salient role of religion in Indian culture was very interesting to experience.

In general, I think India is a hard place to visit. The cultural shock is the first hurdle to overcome. But even as I have gotten used to India, I still find it to be tiring and overwhelming on a daily basis. Life is hard here. The infrastructure is poor, there are many layers of bureaucracy involved in almost all aspects of life, and it can be very difficult to accomplish even minor tasks efficiently. Not to mention, I am getting very tired of eating rice with every meal. It will definitely be a welcomed relief to get back to the US after visiting here.

Final Rotation: Medicine

For my final rotation here in Vellore, I choose to do general medicine, in order to get a feel for the different types of pathology seen here as well as general administration of care. As I noted during my first week of OBGYN, the most striking thing I have so far noticed about disease management at the main CMC hospital is how similar it is to our management system in the United States. Each morning, the attending rounds with the interns and residents, overseeing the management of each patient and enhancing the knowledge of the whole team by teaching about each case. The patients are generally receiving top of the line diagnostic tests, including MRIs, biopsies etc, as well as the being treated with the same exact medications utilized in the US. And much of the pathology is similar as well. I have already seen a fair amount of hypertension and diabetes complications, including congestive heart failure, strokes, kidney failure etc. There are some cases of more unusual pathology which is less commonly seen in the US, such as rhematic heart disease (which can result from untreated strep throat) and disseminated tuberculosis. However, I would say the most notable difference between the pathology here and what I am accustomed to at home is the often advanced stage of the pathology on presentation. Because there are more barriers to healthcare here in India (poverty, rural communities with limited healthcare access, service of a large population etc), patients seem to wait longer before eventually deciding to present to the hospital. For example, on the ward today I saw a 42 year old male patient with a history of diabetes who initially presented to an rural outpatient clinic complaining of decreased vision in his right eye and pus dripping from his right nostril and right ear for more than four months. After extensive work up, it was determined that he had mucormycosis (a severe fungal infection, increased risk with diabetics) and he was treated with intensive antifungal treatment for two monthes at this outpatient facility. However, the longstanding fungal infection did not respond to antifungal treatments alone and on admission to CMC, the doctors realized the infection had persisted and tracted back into his cavernous and sphenoid sinuses (essentially, the fungus had invaded part of his brain). He required extensive debridement by neurosurgery and additionally, his right eye had to be removed and the eyelids sewed together to completely eliminate the infection. He is also requiring intravenous antifugal treatment postop. Of course, the outcome in the US may have been the same, but because this man works as a farmer in a rural village, he most likely delayed seeking treatment until he could no longer tolerate the symptoms and became worried enough to get help. And even when he did initially seek treatment at a rural hospital, it was substandard. At the point he was admitted to CMC, the infection was already so extensive it led to him losing an eye. Despite the poor outcome in this man's case, and perhaps in many other cases with advanced disease presentation, the majority of patients here at CMC and in the directly surrounding communities are receiving adequate healthcare in a society that is stricken by poverty and afforded very few luxuries. Thanks in large part to the charity given to the hospital, the physicians are able to care for their patients using the best tools available and do their best to overcome the social circumstances, which heavily influence the variety and severity of pathology seen here.

CHAD Continued

On Wednesday of my CHAD rotation, I was able to witness another unique aspect of the healthcare system here at CMC: nurses rounds. As I mentioned in my last post, on Tuesdays and Thursdays, doctors along with a couple nurses venture out in the community in the traveling clinic on wheels. In this scenario, patients are expected to seek attention at the traveling clinic when it comes to the village. However, some patients do not adequately follow up during these village visits or may require more frequent monitoring than once every 4-6weeks. To better serve noncompliant patients or those who require very close follow up, CMC has implemented "nurses rounds." A few days during the week, two white jeeps packed with a couple of nurses and "health aids" along with a driver visit specific communities and villages to check up on non compliant patients or follow up high-acuity problems. The nurse we rode with explained to me that every nurse employed by CHAD for community outreach is in charge of 15,000 people. I took this to mean that she is responsible for following up the care of people in a localized collection of villages. The health aid that was also along with us is apparently responsible for only 5,000 patients and is able to be more intimately involved in their care. So during the jeep ride out into the villages, the two women (health aid and nurse) discussed their common patients and decided which ones we needed to see on that particular day.

When we arrived at our first community, we were greeted by an elderly lady in an elaborate saree (all the women in all the villages wear sarees, regardless of their economic status). The nurse informed me that this village elder acts a health care liaison for the community and helps the nurse and health aid identify potential patients and monitor their progress. In the first village and throughout the day, we saw many different people with a range of reasons requiring follow up. We saw some simple post-natal visits, a woman monitored for preeclampsia, a young 28 year old bald woman receiving chemo for a ovarian germ cell tumor and a few cases of acute infections such as scabies or febrile illness. The nurses main job during the visits was to check in with the patients, offer education and advice and triage their care to decide if they needed referral to the main CMC hospital. The whole experience was an incredibly unique opportunity to see people in their communities and witness up close what their living situations are like (most people live in relative poverty, however, they seem to have tight bonds to family and community and live a peaceful existence). The system of individualized care in such a vast population is quite remarkable and was very impressive to witness personally. (Since returning to the US, I have read a wonderful National Geographic article about health care administration in India, and their description of health care structure is similar to what I have written about here. Interestingly, the article pointed out that the reason nurses and health care aides who have received some medical education and training can make such a huge difference in India, is that the majority of diseases that people die from, such as starvation, diarrhea and infections, do not require doctor intervention or even hospitals. Most death and disease can be prevented with proper education about infection prevention, breast-feeding, nutrition, home remedies and personal . I did wonder at the time I was there how these women could possibly be making much difference since they don't carry medications or perform procedures. The answer, I now know, is that even minimal community education can keep the population healthy without any need for advanced interventions.)

After having two days of such eye-opening experiences, both Stefanie and I remained in the outpatient clinic today, seeing routine patients visits with the CMC interns (although I guess it depends on your definition of routine...for example, I saw several cases of rheumatic heart disease and a couple parasitic infections, which isn't exactly routine in the US). I saw one elderly woman, about 65, with complete uterine prolapse, meaning her uterus essentially extended completely out of the vagina. It was very physically uncomfortable for her and she had delayed seeking treatment most likely due to embarrassment. After examining the patient with one of the OBGYNs, the doctor informed the patient she would require a hysterectomy and needed referral to the main CMC hospital. The woman looked very concerned with this news and spent a lot of time arguing with the intern. Later, the intern filled me in on the conversation, explaining that the woman was really resistant to having the surgery. He informed me that in India, having a hysterectomy represented loss of womanhood and femininity. In the US, it is more comparable to have a mastectomy. Even though removing the uterus has no aesthetic ramifications and despite the fact that this woman was postmenopausal and could no longer have children, the uterus still represented fecundity and helped defined a woman's role in Indian society. As I have noted in prior blog entries, I just find inextricable linkage of social norms and women's healthcare in India very fascinating, which adds a whole different dimension to administering care in this country.

Overall, the week was very interesting with a huge range of experiences packed into just a few days. I think the rotation has given me a much better sense of the Indian population and the particular challenges of caring for such poor communities with minimal resources and incredibly underdeveloped infrastructure.

Week 2: CHAD

This week, I transitioned from the main hospital to the community hospital here in Vellore called CHAD. The clinic site is located on the same campus as the medical school in Bagayam, which is about 15 minutes away by autorickshaw. The purpose of the community hospital (which has both outpatient services and a small inpatient ward) is to service the outlying communities and villages around Vellore. The healthcare structure utilized by CMC to serve the rural Indian villages is very intersting and quite different from traditional health care offered by larger urban hospitals. There is, of course, the more traditional services offered at the hospital itself, but a large portion of the healthcare is administered by doctors and nurses who go into the local communities to provide care because so much of the population is poor with limited resources and no ability to come into the more urban centers.

My second day of CHAD, I was able to witness the outreach-oriented healthcare by riding along with the traveling clinic, which basically consists of a large bus that acts as a clinic on wheels. On this particular Tuesday, just as it happens every Tuesday and Thursday, a group consisting of two doctors, two nurses and a driver venture out into the surrounding villages. The healthcare workers visit three different villages each day, spending about 2-3 hours in each spot, depending on the number of patients. The village range from extremely rural, sparsly populated areas to small towns nestled in the mountains outside the city. The first village we visited was very rural, with most of the structures consisting of deteriorating walls with thatched roofs. One of the doctors set up a small folding table with a few chairs under some trees and the patients quickly began arriving (as a side note, Indian people hate waiting their turn....so there was a lot of bickering and cutting in line involved in seeing the doctor). The patients who have chronic illness, such as hypertension and diabetes, carried a white card with them, their "Chronic Disease Card." If they carried one of these cards with them, the doctor would look it over, do a cursory physical exam, take their blood pressure and then decide what to prescribe for them. Once this was accomplished, the patient could then take their prescription over to the bus, where one of the nurses acted as a pharmacist, doling out medications. It was really a remarkably efficient system considering the patient volume and the inaccessibility of most healthcare to these villages. With this system, patients who may or may not even have access to running water or electricity are able to manage chronic diseases with remarkable efficacy. And they are seen about every 4-6 weeks, as the traveling clinic cycles around to every village in about that time period. A doctor visit every 4-6 weeks is more frequent than most US patients managing chronic diseases will have, which is amazing. However, while the community outreach structure works well for managing chronic illness, it is much more difficult to implement an effective system for acute illnesses or ailments requiring diagnostic or surgical interventions. For example, we saw one very elderly woman (she looked about 80 years old, but she didn't really know how old she actually was) who had a nonreducible epigastric hernia (meaning that her intestines had become stuck in this bag of skin protruding from her stomach and could no longer be pushed back inside). This is a situation that requires surgical intervention or eventually, the intestines will become twisted on themselves, cut off their blood supply and die. However, this elderly lady informed the doctor that none of her relatives were willing to drive her to CMC for evaluation and treatment and since there is no system in place to transport these kinds of patients, the hernia may eventually cause serious problems for this lady. So even though CMC and healthcare in India has invented many innovative ways to serve its unique population, there are still large gaps where patients do not receive proper care.

The remaining two villages I saw as I traveled around with the clinic on wheels were very similar experiences to the first. I saw a large number of chronic disease patients who were well serviced, very thorough antenatal care provided by a doctor who examines pregnant women inside the bus, but many acute illness or chronic illness requiring more complex care which could not be treated. However, for such a large, underserved and desperately poor population, I would say the healthcare here is innovative and very effective.

OBGYN Continued

The end of my first week at CMC is nearing and I will move on to a community health rotation next week. OBGYN has been quite interesting, but mostly, because of its similarity to the practice of obstetrics and gynecology in the US. Granted, the equipment and facilities are not as nice or high tech, but it is essentially very modern and demonstrates an extremely high level of care. I guess I expected that many modern practices would be lagging here in India, but that obviously isn't the case.

One of the most interesting things I got to do during the week was participating in Grand Rounds. In the OB department, Grand Rounds consists of the head of the department (who is a wonderful female physician, Dr. Alice George) going around with all the faculty members and residents and reviewing every inpatient's hospital course. The resident typically presents the case and then Dr. George proceeds to pimp or quiz them about the case. The whole experience is very similar to our system of resident learning and teaching in the US. Most of the cases presented (both OB and GYN) were typical scenarios seen in American hospitals: hysterectomies for excess vaginal bleeding, mothers with severe anemia being monitored after delivery, antenatal montioring of high risk pregnancies etc. Therefore, for me, the most interesting part, aside from the valuable teaching that was done, were the differing social implications resulting the surgeries and interventions done by OBGYNs in India. For example, one woman we saw was a 24 year old female one day post-op from a total abdominal hysterectomy and bilateral salpingoophorectomy (ovary removal). The patient apparently had a history of terrible endometriosis, which had deposited on her ureters and scarred them, causing obstruction of her left ureter which had already lead to permanent kidney failure on that side. In an effort to prevent further complications from her endometriosis, the uterus and ovaries were removed. However, Dr. George belabored the point that this lady would most likely become somewhat of a social pariah due to her infertility. She surmised that her husband would most likely imminently leave her since she is unable to bear children. And without a husband or children, there are very few roles available to women in India (most women in India are housewives and are fully supported by their husbands). Dr. George spoke of past patients whom, under similar circumstances, had be sterilized at a young age only to be subsequently ostracized from society. The whole conversation was a very intesting commentary on Indian society and how it differs from what I am accustomed to.

Which brings me to one final observation about Indian women in relation to their role as childbearers. First, whenever I saw babies born throughout the week, I never saw a single mother display any trace of emotion after giving birth and seeing her baby. I am not sure if this is because emotional displays are unacceptable here in India or because many women are rather indifferent to their primary role as childbearer. I was informed by the OBGYNs that mothers are usually especially disatisfied if they give birth to girl, particularly if they had many female children at home but do not yet have any boys. In fact, a local informed me that dissatifaction with and discrimination against female babies has been so severe in the past that many women would have an abortion if they found out they were having a girl. Consequently, it is now illegal for an OBGYN to inform a woman of the sex of her child during pregnancy. Having a male to carry on the family name is obviously vitally important in this culture.