The Dengue fever outbreak of 2011 has been worse than anyone expected. It arrived sooner than anticipated, and is far more widespread than anyone could have prepared for. Starting in early August, Dengue fever has in two months affected many thousands of people. Almost 200 have perished. Every day it seems there are a few more lives lost to this public health disaster. The relentless media reminds us every day that no one is safe, and people everywhere are in anguish over this ever-present mosquito and the virus it bears.  

On the 10th of August I wrote that a Dengue outbreak was imminent. I am no Nostradamus; I was merely reporting what I was seeing in my lab. Today, at the risk of sounding silly, I want to tell you that I think the Dengue outbreak is finally coming to an end. At the least it seems the worst is behind us. There has been a steady decline in the number of new cases diagnosed over the last week or so.

While this outbreak may be coming to an end, we all know that Dengue will be back. There are many lessons to be learned from the crisis and our collective response to it. I thought this might be a good time to discuss some. So here are a few things that I have learnt:

- Cleanliness is half the faith for a reason. Perhaps it was going to take a disaster such as this to remind us of the sheer importance of hygiene and cleanliness. Dengue seems to be on the decline. I hope the lessons in cleanliness we have had to learn in a hurry will stay with us for some time to come.

- Mosquitoes love water! If we have gathered one thing from the unending footage of the bold chief minister draining water coolers, it is that water sits and collects in more places than we might imagine. And every such small puddle of water could be a breeding ground for a new generation of mosquitoes.

- Dengue can kill in more ways than one. As doctors, our understanding of Dengue fever and its management has taken a quantum leap in the last 6 weeks or so. Patient management has grown from simply the prevention of bleeding to the management of third compartment fluid loss as well. And we know that 80-90% of Dengue fever patients are asymptomatic; they never even know they had the illness! I myself was not sure how useful the Sri Lankan and Indonesian experts would be in this time of crisis. I have to admit that the knowledge they imparted and the endless seminars and lectures based on their experience and insight have raised the general level of expertise in the local medical community.

- Perhaps most importantly, we now know that no one can do this alone. Two months ago, it was Shahbaz Sharif Vs Dengue Fever. Today, it is Us Vs Dengue Fever. The most successful initiative of the Punjab government in the face of this crisis has been to get the public involved in public health. There is a limit to how much fumigation the government can do. There is a limit to how many water coolers Shahbaz Sharif can drain for the benefit of TV crews. This is a public health issue, and unless everyone gets involved, we don’t stand a chance.

If experts are to be believed, Dengue fever will be back in the spring. And it is going to be with us a few more times after that as well. I hope and pray that it is never as bad as it has been this year. Hopefully we will remember the lessons of 2011, and they will better equip us to deal with this menace in the future.

I saw a patient yesterday. She was a 40 year old mother of three, her youngest daughter only 6. The patient had gone to a general surgeon because of a breast mass, and she had been referred to me for diagnostic work up.

The lady told me that she had had the mass for over a year. I asked her why she hadn’t seen a doctor earlier, and she said that she hadn’t wanted to draw attention to herself. The family had limited resources, and she had not wanted to become an additional burden.

My patient has cancer. I suspected as much the moment I saw the mass. And when I saw the slides, my suspicions were confirmed.                                                                                                                                                       

The year was 1999. I was a final year medical student. We were attending the Out Patient clinic at Mayo Hospital in Lahore. With our professor we saw patient after patient who had ignored a breast mass for a long time before finally giving in to the pain or weakness. I remember one patient in particular who had come from a village near Peshawar. She had ignored her breast mass for a few months. Then she had sought the blessings of her local ‘Pir Sb.’ When that didn’t work, she had gone to a ‘hakeem,’ who had given her a potion which had obviously not helped. More than a year after first noticing her breast mass, she had finally gone to see a local doctor, who had referred her to Mayo Hospital. By the time she made it to Lahore, the cancer had replaced all of her breast and spread to her axilla and beyond. A mass which could have been removed completely a year earlier had now become incurable.

These are sad stories. And these stories are not at all uncommon. Cancer of the breast is one of the three most cancers among women. One in nine women will develop breast cancer in her lifetime. But breast cancer does not develop overnight. It usually begins as a small mass in the breast, which grows ever so slowly for a long time. It is at this stage that a woman should go to a doctor and have the mass examined and biopsied. Most breast masses are benign, but the cost of ignoring a mass that might be malignant is very high. Every day women die of breast cancer which could have been treated if detected in time.

In my experience, most women who don’t see a doctor for a breast mass are reluctant because they are shy to talk about the issue. In other cases, women simply don’t want to ‘waste’ limited resources on their own health. These are terrible reasons to risk the life of a mother, a sister or a daughter.

 Unless we start to get over our hang ups and actually talk about this issue, we will never be able to educate women and their families about the risks of breast cancer. We must change our collective attitude towards women’s health and breast cancer. Only then will these sad stories become less frequent.