Kiss of Death

Cigarette manufacturers may have been facing government regulations and restrictions in advertising, but other smokeless forms of tobacco and narcotics consumption are on the rise. Gutka, a dry, relative non-perishable mixture of areca nut, lime, sandalwood fragrance with tobacco, has become the most socially acceptable form of tobacco consumption in Pakistan and is fast replacing the more traditional paan. Its use is acceptable in all age groups and across gender, which has lead to serious health concerns and alarming rise in tobacco related diseases, especially amongst women and children. The contents of gutka are placed in cheek pocket, chewed, relished and then spitted. It is locally produced but huge quantities are imported from India. According to an Indo-Asian News Service Report (IANS) published in India enews, 45,000 kilos of gutka is being sold in Karachi everyday. Unlike cigarettes, gutka comes without a health warning and lack of awareness of its impact on health increases its consumption.

Gutka consumption is very high in the school age children, some as young as 8 years old. According to a study, ‘Prevalence of areca nut chewing in school children’ conducted by students of Department of Social Work, University of Karachi in 2004, 93 per cent children of 50 government and private schools in Saddar Town spent their pocket money on buying chalia or supari and 7 per cent on paan and gutka. What is more alarming than these figures is that the children who are buying chalia and supari can very easily graduate to more harmful substance consumption because of its ready availability. Another study conducted by students of department of community health sciences, Aga Khan University in 2006, says that up to 70% of the primary school children have been reported to chew some form of chalia (areca nut) or gutka (areca nut treated with tobacco) on daily basis in Karachi.

Kashif is an eighteen years old auto mechanic visiting OPD at Abbasi Shaheed Hospital. He has been consuming gutka since he was 11 years old. He cannot eat anything and cannot open his mouth properly. His condition is what doctors call oral submucous fibrosis. When asked why he started eating gutka, he said that it was what everyone else was eating; it was sweet, cheap and easily available. ‘I did not know that it would lead me to this condition,’ he said while keeping a cloth on his mouth to control the dribble.

Dr Anwar Alam of Internal Medicine at Abbasi Shaheed Hospital corroborates this. “The reason behind the surge in oral diseases in the past decade in the younger people is the rampant use of gutka and gutka became this popular because it was easily available everywhere and it was convenient to use.” It must be noted that other forms of tobacco are not this conveniently consumed or readily available and have some stigma attached to it to make it a little less socially acceptable. For instance, chewing tobacco with paan is not convenient, it requires either setting up an elaborate paandaan or frequent visits to the paanwala. Secondly, it may be acceptable for older people to consume paan, but children generally are not allowed to eat paan. Similarly, there is social stigma attached to tobacco smoking of women so they may not take up smoking that readily or even if they do take it up, they do not do it as openly as men do. However, gutka consumption is free of all the prejudices and inconveniences. It is as easy to carry as a small candy, it is not messy, it is fragrant, one does not need to go to a paanwala exclusively to buy it, it has no social stigma attached to it and hence can be consumed by teenage girls and adolescent boys. What most people do not know is that its health risks are just as injurious, if not more, as that of chewing or smoking tobacco.

Apart from submucous fibrosis which is precancerous lesion characterized by stiffness of oral tissues resulting, at times, in inability to open mouth, other gutka consumption related diseases are leukoplakia (white patches in the mouth cavity) and erythroplakia (red cell accumulation in mouth), and oral cavity and esophageal cancer. Submucous fibrosis, leukplakia and erythroplakia are all pre cancerous lesions, but submucous fibrosis has a very high transformation which means that if not treated, it can become malignant much faster than the other types of pre cancerous lesions. According to Dr Alam, every second patient in Abbasi Shaheed hospital’s ENT ward is suffering from one or the other forms of pre cancerous lesions. “The saddest part is that even when we tell patients that gutka contains the same chemical which is used in leather tanning they continue to use it, resulting is more severe, at times malignant lesions,” Dr Alam added.

Shamshad Ahmed owns a paan stall in boat basin. He sells an average of 500 packets of gutka a day which is not high enough by his standards. “People are more affluent in this area so they buy imported cigarettes or paans after they have eaten food in the nearby restaurants. My brother, who owns a paan stall in Mithadar sells about 1500 packets a day. An average costumer buys at least ten packets,” he said.

Apart from the urban centers, gutka usage is as popular, if not more, in rural attachments to the city. The newly built 48 kilometers long road that connects Karachi to Mubarak Village is dotted with various small villages, inhabited by fishermen and their families. Every village has its own small shop and they may or may not stock basics such as milk or onions but almost every shop sell packaged and unpackaged gutka which is the perhaps the most popular item. Tahira Kaukab, program officer of a local NGO Indus Earth that works in the area stated that people in this area may go without food but will not forego their gutka addiction. She further added that the gutka sold in the coastal belts is often expired and they have found small insects and parasites in the gutka packets.

According to Muhammed Ali Shah, President Pakistan Fisherfolk Forum, approximately 80 per cent people of Ibrahim Haidery who are involved in fisheries related activities, consume gutka. He said that fishermen especially stock up on packaged and locally manufactured gutka before they go fishing in the deep sea. He said that everyone, including women and children, is addicted to gutka. The locally manufactured “gutka puri” is sold for just Rs. 5 and is said to have traces of opium. Mehran Welfare Association, an NGO working on health issues in the coastal areas of Sindh, has conducted a sample survey of 300 gutka addicts in the coastal villages in 2005 and came up with the shocking finding that a good 10 per cent of them were suffering from oral cavity cancer and precancerous lesions. A visit to a local gutka manufacturer in Federal B Area, Karachi, revealed that gutka is manufactured in bathtubs by immersing betel nuts in liquid tobacco and other narcotic addictives such as morphine. When asked, Mohd Anis, the worker who was involved in the process said that he does not know what chameicals and substances are used in gutka preparation. A study, ‘Narcotic Adulteration in Fennel and Betel nuts’ conducted by department of Chemistry, University of Karachi in 2000 reports that 36 samples of Indian and Pakistani brands of saunf supari, chalia and gutka were tested and it was discovered that some of the samples contained tobacco, some contained morphine, and some samples had low heroin content.

A study conducted in India, titled ‘Smokeless Tobacco and health in India and South Asia’ which was published in health journal Respirology in 2003 found that pregnant women who used gutka had a three fold increased risk of having low birth weight infant. Dr Saleema Ghulam who is running a clinic in Gabu Bat (Union Council 8 near Mubarak Village) set up by Indus Earth says that it is very difficult to make the women in those areas understand that gutka is injurious to health, more so when a woman is pregnant. ‘It not only affects the person consuming it but the unborn baby as well. Such babies are either pre mature or weigh less than normal. They are weak and have comparatively less immunity. They are born disadvantaged if their mothers consume unhealthy substances but making them understand is very difficult, especially when I am talking through translators,” she added. Muhammed Ali Shah expressed similar concerns. He said that women in the coastal belt of Ibrahim Haidery especially take gutka before they feed their babies. According to these young mothers, gutka helps in calming their babies and they go to sleep in no time. What they do not know is that they are intoxicating their babies with substances found in gutka.

According to Dr. Yasmin Bhurgari, who is heading the Cancer Registry at Aga Khan University Hospital, cancer of oral cavity, ranks sixth in the world in both sexes. It is the third most common cancer in men in developing countries. However in Karachi, the malignancy ranks second in both genders. The incidence, she claimed, is the highest in the world.

According to Dr. Ahmed, an average of 6 – 8 people come in every day to Abbasi Shaheed who are suffering from gutka related diseases. In some cases, it is too late as people prefer to go to quacks and hakeems and only go to the doctors as the last resort. Azfar Ali is one such victim. He is 12 years old and suffering from submucous fibrosis. He has been a gutka user for the past three years. ‘I never had gutka when I used to go to school, but when my father died, my mother took me off school and sent to a Khada where I started working as an embroidery apprentice. Everyone was eating gutka so I also started eating it. I never knew it would lead to this,” said Ali. His condition is worsened because an uncertified hakeem has been putting some balm in his mouth which has infected the lesions.
While the burden of oral cancer is increasing on public sector hospitals, which have limited resources, no preventive measures are being taken to check the widespread use of chalia and gutka, especially among school-children. Pakistan is in dire need of cancer control program and the first and most obvious step should be public awareness about the probable causes of cancer.

Though the rate of oral cavity cancer in Pakistan is estimated to be among the highest in the world, no concrete efforts seems to have been taken by concerned authorities. No legislation has taken place to control the use of betel, chalia, gutka and tobacco in Pakistan. Campaigns against cigarette smoking are beginning to gain momentum; but the smokeless forms of tobacco consumption are perceived to be safe and daily use commodities.

In 2002, former ombudsman Justice Haziqul Khairi suggested immediate ban on production, sale and use of gutka but nothing materialized. In 2005, under former education minister Dr. Hameeda Khuhro, ministry of education drafted a bill to ban sale of cigarettes, betel leaves, gutka, and betel nuts within one kilometer of schools and colleges but that too got lost in official and legal labyrinths. In all honesty, with schools in every nook and cranny of the city, it would have been impossible to implement that law of banning the sale of paan, gutka, and cigarettes within one kilometer of educational institutions. Provincial government of Ghulam Arbab Rahim also considered banning sale of gutka in Sind in 2005 but that decision never saw the light of the day. (reported in dawn)

It is interesting to note that unlike India, the gutka phenomenon took the urban population by storm without any advertising. There have been some marketing about paan masala and supari, but gutka marketing generally remained out of the mainstream media. One can only see posters claiming most stupendous gutka next to paan stalls in low income localities in Karachi but that alone cannot create such huge demand for it. According to the report conducted by community health students at AKU in 2006, beliefs about the medicinal benefits of gutka and chalia greatly contributed to the sales of gutka. The proportion of people who develop the habit after using these products as a home remedy for digestion, toothache and common cold, remains to be determined but the study conclusively stated that ‘Family and friends’ were responsible for the introduction of gutka, chalia and other tobacco based items. Community health practitioners need to focus interventions directed towards educating the families regarding the harmful effects of these substances and also to correct misinformation.

Mumtaz Khaskheli, who takes care of operations of Health and Nutrition Development Society (HANDS), an NGO working in health, community development and poverty alleviation, rural Karachi says that staff in their school and clinic is trained to inform everyone about the hazards of gutka and tobacco consumption, they hold workshops in community where health workers share knowledge about safe drinking water, importance of hygiene and consumption of injurious substances such as gutka. Such models can be replicated in other communities as well.

Mass campaigning about the hazards has to be done through print and electronic media. Visual representation of the handicap caused by the use of these products can be more effective for this purpose. All state run and community health centers must put up posters warning people of hazardous implications of gutka consumption. Health authorities must step up and play a more proactive role to formulate the policies to limit the use of these items. Heavy duties on the industry, import and marketing of these items should be imposed. Warning signs on gutka sachets should be mandatory, like cigarettes. All chalia sponsored music videos showing actors using these products as something cool should be banned. Health care professionals have to be proactive in the counseling the high risk patients in particular and others in general. Without such measures, the incidence of oral cancer and other gutka related diseases will not only keep on rising, but also keep on affecting younger age groups.
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The Don Connection


Though largely unreported in local media, Indian Don Dawood Ibrahim is said to be responsible for initiation of large scale industrial manufacturing and sale of gutka in Karachi.

According to various reports printed in almost all Indian news papers (NDTV, Indian Express and Times of India to name a few), two Indian gutka barons who control a huge part of US$ 1 billion gutka sale across the globe, approached Dawood Ibrahim to settle some dispute. During mediation, Dawood asked them share their gutka manufacturing know how. They arranged for machinery to be exportrd from Surat and Mumbai to Karachi via Dubai.
According to Indian Police, 15 gutka making machines are sent to Pakistan. And according to Mumbai tabloid mid day, Dawood Ibrahim rakes in a cool Rs 150 crore a year selling gutka in Karachi. According to Times of India, two Scotland yard officers traveled to New Delhi in May 2007 to probe on the gutka case.

According to investigators in India, Dawood has started using an ingredient called krishnamess, manufactured in Switzerland, which is used to enhance the taste of gutka. It is sold at Rs 30,000 per kg. According to the media reports, Dawood is also planning to open a plant in Dubai.