The mounting public health crisis in Pakistan

When the recent floods of Pakistan started rampaging through the northwestern parts of the country, they were initially overshadowed by Pakistan’s worst airline disaster in history when a plane crashed into Margalla hills adjacent to Islamabad. Now again, the floods that took 1,600 lives; affected 20 million more; inundated 62,000 square miles (the size of England), including 3.2 million hectares of agricultural land; snatched a million heads of livestock; and damaged or destroyed 2 million homes, 7,000 schools, and 514 health facilities have again been forgotten, this time presumably by the goldfish-esque attention span of global stakeholders. However, while the floods may have receded from newspaper front pages and television headlines, the floods’ actual impact seems to have much greater staying power.

These floods represent one of the greatest public health challenges in modern history. In a conventional model of disease, the floods represent an "acute on chronic" condition, with Pakistan having been previously afflicted by several chronic maladies such as incessant low- and high-intensity civil war, a crumbling economy, ineffectual governance, previous bouts of disaster such as the 2005 earthquake that killed more than 100,000, and nearly 4 million individuals displaced internally from their homes due to Pakistan’s various internal conflicts.

In conditions where infectious disease transmission was always high, the disruption of living quarters, widespread water contamination, breakdown of hygienic practices, close proximity in temporary camps, and rampant malnutrition have resulted in an infectious disease catastrophe. In August alone, the World Health Organization (WHO) reported 4 million cases of diarrhea, pneumonia, malaria, and skin conditions that had largely resulted from the flood conditions. Cholera outbreaks have also been reported from flood-affected areas. From Oct. 15 to 22, WHO reported about 258,000 consultations for pneumonia, diarrhea, and suspected malaria. Furthermore, dreaded diseases such as dengue and Crimean Congo hemorrhagic fevers have been reported from the field, along with measles encephalitis and neonatal tetanus. 

The resurgence of polio in flood-affected areas is an event of global implications. In October, more than half of all polio cases in Pakistan were from flood-affected areas. It is important to note that Pakistan is one of only four countries (Afghanistan, India, and Nigeria the others) where polio is still endemic, with Pakistan accounting for the majority of cases among endemic countries this past year.

Floods are known to have a lasting mental-health impact on those affected. In addition to a loss of economic subsistence, family-member displacement, and the horrors of the flood itself, this disaster has arrived in the wake of several previous exacerbating factors. Rates of post-traumatic stress disorder (PTSD) have been reported up to 75 percent in populations displaced from the war in the tribal areas. These floods, known to increase the incidence of PTSD and depression, may be the final push for those trapped in a vicious circle of misery and destitution. Addressing mental-health disorders is especially important because someone who is mentally traumatized or depressed is less likely to take the considerable effort required for rehabilitation.

Several agencies are involved in disaster relief, primarily the government, the armed forces, the National Disaster Management Agency (NDMA), and international aid agencies such as the WHO, USAID, UNICEF, Médecins Sans Frontières, as well as a large cadre of civilian volunteer efforts. Nevertheless, no central direction exists as to relief efforts, resulting in an asymmetrical distribution of resources, resulting in both redundancies and inaccessibility. The NDMA does not even have an official overlooking the evolving health crisis. While the armed forces have provided the most visible relief, they remain stretched thin due to their combat obligations in Pakistan’s tribal regions and the Swat Valley. Actual and perceived corruption in Pakistan’s civilian government, meanwhile, remains a great deterrent to volunteers and aid agencies that would otherwise extend the government their assistance.

According to a recent report from Oxfam, aid for flood victims has virtually dried up. Although the government has failed to effectively advocate for the millions affected, several other factors are at play too. While foreign governments have raised the profile of the disaster, their respective citizenries has not participated as vigorously as they have in recent comparable disasters such as the Asian tsunami and the Haiti earthquake. One prime reason is that Pakistan is associated in the West almost entirely with its terrorist problem. The geostrategic argument for aid has thus been far more resonant than the humanitarian one. Beyond the thousands of innocent people who the terrorists have killed along with ripping the fabric of social cohesion apart, their greatest victory lies in isolating 180 million Pakistanis from the international community, despite the fact that Pakistanis have perhaps suffered as much as any other nationality at the hands of terrorists.

The disaster, as those operating in the field will describe, is far from over. With people’s land and livestock destroyed, their ability to sustain themselves beyond the dramatic phase of the disaster has been diminished. With winter fast approaching and little or no shelter available, the plight of those languishing in disease-ridden camps will only escalate. A monumental food shortage is likely in the coming months, rendering the flooded areas even more susceptible to disease. The geostrategic implications of widespread epidemics, especially with the fate of the war in the tribal regions delicately balanced, are hard to overlook. Unless public health is made central to national and international relief policy and the focus of the international community is sustained, the sick man of South Asia might not recover from this newest bout of illness. 

Haider Warraich, MD, is a research fellow at Harvard Medical School. He is a graduate of the Aga Khan University in Karachi, Pakistan, and the author of the forthcoming novel, Auras of the Jinn.