Ghafoor Hussain Shah is a 56-year-old teacher and father of eight children in Pakistan-administered Kashmir. According to tribal customs in Pakistan, Shah said he is expected to arrange the children's marriages within his extended family.

However, Shah knows about the potential risks of genetic disease prevalent in children from inter-family marriages. He married his maternal cousin in 1987, and three of their children suffer from disorders.

Shah told DW his son's brain did not develop to a normal size. One of his daughters has a speech disorder and another has hearing problems.

"My biggest regret is that they could not get education," he said. "I am always worried about them … who will look after them after my wife and I are gone?" he added.

Despite the risks of genetic disorders, Shah said there is enormous social pressure to adhere to customs calling for cousins to marry. Anyone who refuses to offer their children for marriage within the family risks being ostracized.

Shah said he had to marry off his one son and two daughters to close relatives. His family's medical history includes cases of blood disorders, learning disabilities, blindness and deafness. Doctors have said inbreeding could be to blame.

Pakistan's 'genetic mutation' problem

According to a 2017 report on genetic mutations in Pakistan, the "heterogenous composition" of Pakistan's population, including high levels of "consanguinity" has led to a prevalence of genetic disorders.

The report introduces a Pakistan "genetic mutation" database, which identifies and tracks different types of mutations and the disorders they lead to. According to the database, more than 1,000 mutations have been reported in 130 different kinds of genetic disorders found in Pakistan.

Huma Arshad Cheema, a pediatrician specializing in genetic disorders, told DW that Pakistan has a huge burden of generic disorders due to inbreeding.

She said specific disorders can be pinpointed to particular castes and tribes where inter-marriage is common.

One of the most common genetic disorders seen right now in Pakistan is the inherited blood disorder, Thalassemia, which keeps red blood cells from absorbing oxygen.

Genetic testing and pre-natal screenings for hereditary disorders are not widely available in Pakistan, Cheema said, adding that many health facilities also lack the capacity to treat genetic disorders.

Why do cousin marriages continue?

Karachi-based health expert Seraj ud Daulah said that the practice of cousin marriages in Pakistan can be traced to Islamic religious doctrines.

"I asked clerics to help create awareness about genetic diseases, asking them to explain to people how cousin marriages are contributing to the rise in genetic diseases," Daulah told DW.

However, he said the clerics he spoke with flatly refused, claiming that such marriages are in accordance with Islamic Sharia law and the traditions of the Prophet Mohammad.

Shah said many families in Pakistan go through with consanguineous marriages because they believe it is called for by their Islamic religion. Even if the government were to make such marriages illegal, it would be met with fierce resistance, he added.

Tribal and caste systems are deeply rooted in remote areas of Pakistan. Cheema said that the caste system, particularly among the Arain people living in Punjab province, is especially rigid and leads to many inter-family marriages. She said several genetic disorders are commonly found in this community.

In Pakistan's western province of Balochistan, the southern region of Sindh, and in the northwestern provinces, tribal systems dictate family life.

Ghulam Hussain Baloch, a resident of Balochistan, told DW that marrying outside of your tribe is considered a major social taboo. The situation in Sindh is not much different, where marriage outside one's clan or tribe could lead to murders and tribal clashes.

Health officials respond

In March 2020, the government in Punjab formed a task force aimed at preventing genetic diseases. The children's hospital in Lahore is now offering free genetic screening services in cooperation with Germany's CENTOGENE diagnostics company and other international organizations.

Cheema said pre-natal screening will help parents decide whether to terminate the pregnancy in cases where lethal disorders are detected. Early detection can also aid treatment of a child born with a hereditary disorder.

"We have screened 30,000 families in Pakistan with suspected genetic disorders," an official from Punjab's health department told DW on condition of anonymity.

Health expert Daulah, however, said that more needs to be done to change people's mindsets on the danger of having children with close family members.

"In religious matters, people have blind faith and they do not want to listen to any logic," he said.  

"Perhaps if the government asked all clerics to spread awareness about the rising number of genetic disorders, and its connection with cousin marriage, then perhaps more Pakistanis would pay heed," he added.

Edited by: Wesley Rahn