Dealing with Medicolegal Poisons

I am not a medicolegal officer. Yet a mere one-week long, sketchy training workshop by a very uninterested team of Medicolegal experts and presto: according to GoP, I am able to handle the legal intricacies of any medicolegal case, be it a burn victim, gunshot wound, suicide attempt, acid attack, strangulation or an amputation case. Working in a peripheral – otherwise known as rural – setting, my medical mind, meagerly trained in Pakistan Penal Code, has dealt with many such cases. But the origins of M/L officers in rural healthcare settings is a tale for another time. Today, I discuss the one specific occurrence which is noticeably the most frequent of all the M/L cases presented to our team, and that is the use of Kala Pathar.

There were times when my colleagues would be dealing with the Kala Pathar medicolegal cases and post-mortems, and I sitting next to them would intend to inquire about this very recurrent yet alien pathar, but the heavy list of patients on my record would always push the thought away. Until I was faced with a chance to deal with such a post mortem case myself.

The dead was an 18-year-old girl who had run away from her house 06 months back, with her alleged boyfriend whom she had married in secret. The brother of the deceased was obviously not happy with her taking charge of her life and making an independent decision. He had been searching high and low for both of them ever since. The newlyweds managed to stay hidden for 06 months. But the hide out couldn’t last forever. The girl’s family found them, brutally attacked them and took their girl back home.
Now here the account gets confusing. The girl didn’t live to see the next day under her biological family’s care. The father and the brother of girl claim that the boy slipped into their house and made their beloved daughter drink the water with Kala Pathar in it so as to kill her. The mother’s narration is different as she says that their heart-broken daughter drank the water with Kala Pathar in it on her own accord, to rid herself of the brutal life she could foresee in her father’s home. While the doctor on duty with me had a theory of his own, which seemed most believable. He said that the father and brother have given the water with Kala Pathar to their girl themselves, to kill her for ‘dishonoring’ their family.

What actually happened, is not the job of a M/L officer to find out. I was only assigned to check whether the cause of death of that girl is actually the Kala Pathar itself or not. Finding the truth amidst their conflicting histories was left up to the lawyers to investigate and decide about. This case, however, gave me a much-needed chance to look into this deadly pathar – what actually is this pathar? What is its use? what is its chemical formula? What is its mode of action? Why is it so lethal? And if it is so lethal, then why is it so readily accessible?

Chemically known as Paraphenylenediamine (PPD), Kala pathar is a highly toxic ingredient present in hair-dye, especially in shades on the spectrum of golden-blond to black. Hair dyes contain PPD agent in concentration ranging from 0.2%-3.75%. Pure PPD comes in the form of white grains or crystals. It is crushed, mixed with henna for darkening and used in hair dye to enhance its color. It is actually a coal – tar derivative which turns brown on exposure to air and produces an allergenic, mutagenic and highly toxic base. Other than PPD, Kala Pathar also has minor contents of diamine, sodium ethylene, diamine tetra acetic acid and propylene glycol.

Oral ingestion of toxic doses of PPD can lead to the development of first and foremost laryngeal edema (which can cause severe respiratory distress), rapidly developing angioneurotic edema (which includes swelling and puffiness of eyes, lips, throat and tongue along with profuse redness and clustered rash), chocolate colored urine, hemodynamic instability, rhabdomyolysis (which can lead to Acute Renal Failure and then Renal Tubular Necrosis), cardiotoxicity (which can result in fatal arrhythmias) and eventually, swift death within the first 06 – 24 hours. It is worth mentioning here that the amount of PPD which can cause systemic poisoning in a patient of average built is merely 03 grams, while the lethal dose is only 07-10 grams.

The time leading up to the aforementioned ‘swift’ death is also a trial in its own because swelling which develops in throat and tongue can hinder the swallowing – that might lead to choking – obstruct the airways and impair breathing. This requires immediate surgical intervention – tracheostomy – to prevent respiratory arrest. PPD can cause multiple organ dysfunction in patients as well.

The optimum method of managing these poisoning cases is the multi-disciplinary approach involving primary care physicians, intensive care physicians and nephrologists – a dream team always lacking in the rural setting which is always brimming with such cases. In addition to this, the management strategies are not very diverse either. Apart from Gastric Lavage (Stomach wash) with Charcoal very 4 – 6 hours, upper airway tracheostomy and aggressive supportive management, no specific antidote has yet been successful in reversing the grave symptoms.

The extent of harm is dose dependent. It varies from patient to patient and largely relies on amount of dose ingested, early recognition, prompt referral, and the supportive treatment (for example, while the liquid forms are more often ingested with suicidal intentions, mortality is higher with the stone forms. Thus, even the form of poison taken can sometimes make the difference in the clinical outcomes).
However, this easily attainable and entirely fatal pathar has proven to be the go-to substance for those with terminal intents – be it suicidal or homicidal. 3/4th of the poisoning cases reporting to the hospital (mostly in South Punjab and Rural Sindh) employ this poison. This begs the question why? Why is this material so popularly used for ill-intended ends? The reasons can be multifactorial: first is its door step availability and accessibility – it is present in almost all homes and at every departmental store, devoid of any regulatory check; Second is its cost effectiveness – 10 to 12 grams of PPD costs mere Rs. 30/- which in the inflated times of today makes self-harm a rather cheap affair; Then is its salty taste as opposed to the bitter taste of other poisons/drugs commonly available; And lastly its ability to cause swift, easy death if taken in correct amounts.

The frequency of these cases being reported in increasing with every passing day. In 2017, Ghazi Khan Medical ICU received 156 cases patients of Kala Pathar poisoning. According to the ICU in charge, more than 27 of those patients, mostly women succumbed to their deaths within the first 03 months of the year. If we look at the data from South Punjab alone: more than 150 lives were lost in 2016, and more than 120 lives in 2017 due to PPD poisoning. In 2016, out of 703 patients admitted in BVH Bahawalpur, for Kala Pathar poisoning, 150 died within the first 12 hours. In 2018, out of 934 patients admitted in the same hospital, 202 had met their demise. In 2018, more than 600 cases of attempted suicides were registered by ingesting Kala Pathar only in South Punjab and only God knows how many went unregistered. The tally of attempted suicides by PPD increased to 800 in 2019. (There is no sound, verifiable data present for the year 2020 but it is unlikely that it shows any encouraging picture).
Paraphenylenediamine poisoning is not a phenomenon restricted to Pakistan only. It is reported globally although, more so in the underdeveloped and developing countries. The first systemic PPD toxicity was diagnosed in the owner of a hair salon by Nott in 1924. During the 1990s, an 11-year retrospective study (1992 – 2002) of more than 370 cases established PPD as the leading cause of poisoning including both homicidal or suicidal cases. This study was published by Poison Control Centre of Morocco. A similar, but small study constituting more than 150 cases revealed the same in Khartoum, Sudan. Paraphenylenediamine (PPD) poisoning is amongst one of the top emerging causes of poisoning in Africa and South East Asian countries in 2000s.

I was surprised to find out that in Pakistan, when this issue came under the light around 2017 – 18, Section 144 of Criminal Procedure Code 1898 was imposed in Punjab against the sale of Kala Pathar. But this ban was ephemeral. It could not hold the masses off of the product for more than 3 – 4 months. Later on, the situation receded to square one, where around 5 – 6 people were using this poison for suicidal/homicidal/accidental purposes on daily basis. On paper, the ban exists to date. But it exists as an endless cycle of getting reimposed and ridiculed time and again.

In developing countries (including ours) where the suicide is responsible for about 600,000 deaths annually, where suicide is the 3rd leading cause of death in 13 – 40-year age bracket, with its rate steadily increasing with each passing year, a substance so readily available at every 2nd shop in the market is alarming. Use of PPD poisoning is the commonest means of intentional harm. Yet the gravity of the situation has not moved the government to take strict measures for strict regulation and restriction of PPD sale. Hair dye formulation is not a necessity for a society to thrive and has plentiful, better-faring alternatives readily available in the market.

The laws are there but the law-regulating authorities are sadly not interested – as is the case with most of the issues in Pakistan. The Punjab govt and the Home dept. needs to ensure the obstruction of access to this material. Police sector and the bureaucracy needs to step on board. I asked the police constables stationed at our hospital why their department was not proactive regarding this issue? They gave me the old we-have-more-important-things-to-worry-about-than-ungrateful-kids-commiting-suicide. This gas-lighting attitude and heedless, incautious outlook needs to be revised. And fast.

Other than law – enforcement, the civil society needs to take charge on this matter. Effectively barricading the supply of the poison is only half the battle. As a society, we need to nip the cause. The alarming increase in suicide rates – especially among young women – demands awareness campaigns and programs targeted at improving public mental health. In a country where common man thinks that corona vaccine is just another ‘yahoodi sazish for Muslims’ nasal-kushi’, a discourse about mental health is as imperative as it is nonexistent. Establishment of vocational and technical programs for the masses at risk and engaging them in productive skill-learning habits can reduce the incidence of increasing violence amongst them.

It has to be a collaborative effort, one that includes as high up as the govt and as low as the worried mother. In the wake of this pandemic, we are already losing more than we can handle. Debacles like this only add insult to the injury.


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