Pakistan floods: breaking the logjam of spiraling health shocks

Pakistan is facing a cycle of post-monsoon flash floods that cause social and economic disruptions as well as expose displaced populations to health and nutrition shocks. Melting of glaciers, snow and permafrost in the Hindukush region of Pakistan are largely irreversible¹ and in the absence of flood protection strategies, the probability of flooding will sharply escalate.² According to the Global Climate Risk Index Annual Report, a total of 152 environmental crisis events from 1999 to 2018 have caused Pakistan a loss of 0.53% per unit GDP, damage to 197,230 villages, and destruction of over 10 million acres of crops.³ Triggered in the high mountains, the impact of flash floods is acutely seen in the Southern Pakistan provinces of Sindh and Baluchistan. Recent floods in 2022 resulted in 1730 deaths with even more widescale health and social disruption, displacing 8 million persons exposing them to disease and under-nutrition, with 89,000 people in Sindh and 116,000 in Baluchistan still permanently displaced.⁴ Post-disaster assessment estimates that the recent floods will additionally push 8.4–9.1 million below the poverty line reverse health gains.⁵

Floods in Pakistan trigger health shocks by damaging health infrastructure, such as local hospitals and clinics, disrupting medical supply chains, essential household commodities such as milk, food and hygiene items, and contaminating safe water supplies. During recent floods 2.5 million people did not have access to safe or potable water resulting in diarrhoea and dysentery particularly dangerous in young children (Table 1). Stagnant water and open-air exposure resulted in malaria and dengue outbreaks in at least 12 districts of Sindh and Baluchistan. An estimated 1.1 million people became highly food insecure⁶ and similar examples of exacerbated under-nutrition were seen from previous floods in Pakistan. Importantly, with disruption of essential health services, those affected by flooding forego care for routine chronic health conditions, maternity care and life-saving vaccinations. There is also a rise in unwanted pregnancies with loss of access to contraception, menstrual hygiene issues, mental health issues, domestic violence and under-nutrition due to a combination of factors. These largely go un-reported and are poorly monitored for action.⁷

Table 1.

Reported disease volumes, pre and post flood 2022.

Disease volumes	Cases before floods Q1–Q2 2022	Cases during/after floods Q3–Q4 2022	% Increase
Diarrhoea/dysentery <5 years	992,454	1,499,022	51
Diarrhoea/dysentery >5 years	807,573	1,329,943	65
Acute (upper) respiratory infections	4,041,112	5,352,703	33
Malaria	691,197	2,615,745	278
Dengue	2857	27,377	858
Skin infections	1,660,346	2,878,433	73
Conjunctivitis	225,257	264,422	17

Source: Annual District Health Information System Report, Department of Health Sindh Pakistan.

Societal and policy response is overwhelmingly sympathetic and quickly galvanized but continues to be reactive, sporadic and uncoordinated. Despite a repeated, almost predictable pattern of flash floods, pre-emptive planning is not practiced, and focus remains on acute emergency response. The response, couched in humanitarian approach, is narrowly comprised of medical camps and food handouts by government agencies, army, Civil Society Organizations, local charities, medical associations, and UN sponsored clusters. A vibrant philanthropic sub-sector is seen at the forefront of flood efforts in Pakistan, but planning disconnects leads to fragmentation rather than amplified impact. Services and accompanying medicine lists at camps are unstandardised, left to the priorities of diverse service providers, cooked foods supplied suitable for adult consumption overriding attention to supplies of milk, fruits, and vegetables for children. Female staff are lacking and communication skills are deficient despite the high need within affected communities for counselling on disease prevention, self-care for health conditions, mental health, and sexual-reproductive health issues.

The largest unarticulated need of flood response is stewardship towards low hanging best-buys and a coordinated response over a pluralistic society and mixed health systems. Staff mobilisation plans, advance staff training, defining a set of impactful services and advance supplies planning for an essential list of medical-nutritional supplies can be put together based on learning from previous disasters. Pakistan’s speedy COVID-19 pandemic response saw universities emerging as a resource for free-of-cost training⁸ and can be pivoted towards flood responsive staff training. Importantly, organization of a coordinated flood preparedness response require bottom-up district or municipal level planning for practical workable counter measures but districts remain the most neglected administrative tiers for climate preparedness planning.⁹ A consolidated public database of needs and vulnerability assessment in flood prone districts is critical to develop calibrated responses and a centralised planning system can help coordinate planning across district governments, health offices and disaster response agencies. Pakistan has typically relied on short-term humanitarian external funding managed by UN clusters for responding to acute health shocks and post-flood rehabilitation. Foresighted planning can reduce resource demands, mitigate disease, under-nutrition and deaths but will require a modicum of upfront resourcing and a shift of political narrative from acute emergency handling to governance of health risks mitigation.

Contributors

SZ crafted the commentary outline and writing. SZ and ZM together contributed to literature search, secondary data, collation of insights from different coalitions of actors.

Declaration of interests

None.