Soranus, a Greek physician practising in Rome in the 2nd century AD wrote about patients presenting with soft bones and terrible deformities. Frustratingly, he didn’t know what caused this. The patients he observed had ‘rickets’; the name first appeared in 1634 in a record of deaths and casualties among the people of London.
In the 20th century a deficiency of Vitamin D, and therefore low calcium absorption was identified as the cause, since Vitamin D enables the absorption of calcium. Rickets, a childhood disease, is the severe form of this deficiency.
Vitamin D also keeps the immune system working, therefore a deficiency of Vitamin D could be a contributing factor towards other diseases as well such osteoporosis, dementia, diabetes, cardiovascular disease, several autoimmune diseases, cancer, psychiatric disorders, obesity, fibromyalgia, psoriasis, chronic fatigue syndrome, asthma and other pulmonary dysfunctions.
It was also discovered in the twentieth century that an adequate exposure to sunlight, which is easily absorbed by the skin and contains abundant Vitamin D, is a free and simple cure for this deficiency. Startlingly, Vitamin D deficiency is very common in Pakistan. In this sun drenched region this is like running out of ice in the Arctic Circle.
Prevention and cure are unfortunately not simply a matter of improving the diet. Food as a source of Vitamin D is relatively less important because Vitamin D occurs naturally in very few foods. Cod liver oil contains high but still insufficient levels. Other foods such as egg yolks, certain fresh fish and mushrooms also contain Vitamin D but you would need for example more than ten eggs from un-caged hens daily for your requirements. In some countries Vitamin D is added to cereals, margarine and orange juice, but not in Pakistan. In this country the bulk of the population lives below the poverty line and few people have access to healthy or sufficient food. To expect them to afford, say, cod liver oil is like Marie Antoinette’s suggestion of cake for the poverty stricken French masses.
Luckily Pakistan is blessed with abundant sunshine. The best way and free way to get Vitamin D therefore, is for every man, woman and child with an average skin colour to expose as much skin as possible to the sun for several minutes a day. The amount of sun required for persons with fairer skin is less, because fair skin absorbs the sun more easily and is prone to serious damage as a result of over exposure to the sun. For both though, the requisite Vitamin D in the blood is a minimum of around 20 (ng)/mL. The ideal winter level is approximately 35-40 (ng)/mL.
Treatment is of course at the discretion of a physician who can explore the reliability of a blood test result in the presence of other factors. However, broad new guidelines indicate that the average Vitamin D requirement is 1000 IU per day.
Many Pakistanis have no choice except to toil in the sun, still, acquiring fair skin appears to be a national obsession, one that even respected public figures capitalise on. People resorting to bleach and skin whitening creams and soaps are unlikely to expose themselves to the sun.
There is also the cultural taboo against women baring much skin. Therefore:
Doctor to a patient who is severely deficient in Vitamin D: ‘Which part of your house receives the most sun?’
Patient: ‘The roof.’
Doctor: ‘Well then, I want you to sit on the roof with your shalwar pulled up to the knees and your sleeves above your elbows for some time every day. It’s better if you do this in the morning because morning sunlight is most beneficial.’
By his own reckoning the doctor had dealt rather well with the matter, because the woman, covered from head to toe in a black burka could hardly be advised to don short sleeves in public. But, the patient laughing mirthlessly reminded the doctor that he reckoned without the testosterone filled head of the household. She was, she said, never allowed on the roof which is overlooked by three neighbouring houses.
Until the matter is dealt with on other fronts therefore these recommendations can only be reiterated, that a person with Vitamin D deficiency should eat foods rich in Vitamin D, but more important, he or she should expose as much skin as possible to sunlight every day as mentioned earlier. Male patients should be able to comply easily; women must find a spot not overlooked by another house, out of bounds to male servants, inaccessible to male visitors and then comply with these crucial instructions if so permitted by the resident testosterone.
The following advice should be taken ONLY following professional medical guidance: As per current guidelines, in addition to exposure to sunlight persons with Vitamin D deficiency should take a 50,000 IU tablet of Vitamin D plus the regular requirement of Calcium once a week for four to six weeks, and then drop the dose to 50,000 IU every eight weeks for as long as supported by continuing blood tests.
As an alternative to the expensive tablets a vial of Vitamin D meant to be injected may be taken orally if the vial is broken with care and the liquid strained.
Women in purdah should use light coloured fabric, in as light a weave as possible to permit some sunlight through the layers of cloth to the skin. Given their many constraints the people of Pakistan obviously need to work on their religio-social priorities and then manage as well as they can. In most countries the government would help, but perhaps it’s best not to go there for now.