The International

An outbreak of cholera and other waterborne diseases threaten survivors of floods in Pakistan, which could affect up to 3.5 million children according to estimates by the UN Children’s Fund (UNICEF). According to further UN estimates, as of August 24 the floods have claimed at least 1,600 lives, left 8 million people homeless, and directly affected up to 20 million people. The numbers continue to rise after the rains abated. Yet, as the waters recede in the northwest the Indus River surges south into the Sindh province. As early as August 14, at least one diagnosis of cholera was confirmed in Mingora, located in northwest Pakistan’s Swat Valley.

Cholera was already endemic in Pakistan, particularly in urban areas where living conditions are cramped and unsanitary, and in the northern regions, which are annually affected by the monsoon rains. However, the extent of the flooding is likely to greatly accelerate the spread of the contagious disease. Around 62,000 square miles of Pakistan is underwater, roughly equivalent to the size of England. The impact is worse than the combined effects of the previous three great environmental disasters—the recent earthquake in Haiti, the 2004 tsunami in Indonesia, and the 2005 earthquake in Pakistan. To date, however, fewer relief efforts have been made by the international community than in any of those disasters. The World Health Organization (WHO) and Médecins Sans Frontières (MSF), in addition to other organizations such as Oxfam and the International Red Cross and Red Crescent Movement, have been working in temporary clinics but more supplies and funding are needed.

How do the current conditions allow cholera to spread so easily? What is being done to fight cholera and are these actions effective? Finally, what needs to be done now to lessen the impact of the bacterial disease on vulnerable Pakistanis and to prevent future diseases such as malaria, which will be a large threat once the water has receded?

Difficult environment

Cholera is a bacterial infection that causes severe diarrhea, vomiting, and rapid dehydration that can kill in only hours if left untreated; however, around 80 per cent of infections can be cured with oral rehydration salts. Cholera takes anywhere from two hours to five days to take effect, but the Vibrio cholerae bacteria are present in feces for seven to fourteen days after infection, making it very contagious in overcrowded and unsanitary living conditions. If a person ingests any food or water that is contaminated with the bacteria, they are extremely likely to contract the disease. Yet, many people will not even know they are sick because almost 75 per cent of those infected do not experience any symptoms of the illness. If the right steps are taken, a cholera outbreak could kill less than 1 per cent of an infected population. If not, it could kill up to 50 per cent.

The largest problem in Pakistan is the lack of clean water. The electric network has been completely destroyed in the northwest, which means that water treatment plants no longer function. In order to distribute purified water, there must be ways to bring the tanks of water, which have either been sent in from outside the country or retrieved from sanitized wells and repaired water treatment facilities, to small villages. However, over half of the country’s infrastructure has been completely demolished, including highways and bridges, making it much more difficult for aid to reach isolated communities. In addition to the bottlenecks resulting from many people using the few existing thoroughfares, many relief organizations must use donkeys to carry necessary supplies up mountains and through flooded areas.

Stranded groups of people are seen along roads with no protection from the weather. Other families have been seen trapped on a small piece of land surrounded by water with their belongings and animals. In many cases, animals are key to one’s livelihood so families evacuate with as many animals as possible. When people are stranded or relief camps are unable to get access to clean water, people are forced to drink the only water they have, which has been contaminated by their own and animal waste in addition to ground pollutants.

One-fifth of the land has been flooded, forcing more of the population into those kinds of difficult conditions. Relief camps have been set up for the displaced by both the Pakistani government and international and domestic relief organizations, including Pakistan’s Edhi Foundation. While the camps are key to helping the newly homeless and evacuees, their conditions remain a safety threat. According to Tariq Malikan, an Oxfam relief worker in southern Punjab, a camp set up in Kot Mithan, located in eastern Punjab, was housing 300 people in a government school that had four rooms and a courtyard. In addition to the overcrowding, the courtyard did not have proper drainage so standing water became a threat. The government had set up medical stalls in the camp, helping stave off infection, but without the right environment it’s an uphill battle. On August 13, hours after Malikan visited the camp, it had to be evacuated due to the spread of the flood to the town. As the floods have continued south, more people have had to evacuate their homes and are migrating to bigger cities. As of August 24 in Dera Murad Jamali (DMJ), located in the southeast Balochistan province, the official population has grown from 50,000 to 60,000 people, but MSF project coordinator James Kambaki who is working in the city, believes that the actual population count is much higher.

Relief from medical organizations

Providing potable water is a top priority for relief teams. When MSF finds a communal water source, they purify it and distribute it with the support of the local community. The water from that source is delivered to different areas of the town in order to assist the whole community. Alternatively, when MSF locates a private water source, they trade the use of a generator for a few hours in exchange for distributing water from the well to other people. In a recent official MSF report, Joseph Prior Tio, the coordinator for MSF in the Swat Valley, wrote: “The response from the community has been quite good, especially in neighborhoods of difficult access for water trucks. Mosques, schools and individuals are now providing clean water to their local community.” As of August 24, the BBC reports that two million people have received potable water across Pakistan.

In terms of treating cholera directly, the U.S. Agency for International Development’s (USAID) office for foreign disaster assistance has put an early warning system into place that allows cholera to be quickly detected. Meanwhile, the WHO, MSF and other medical teams treat any diarrheal condition as cholera for precaution. Medical staff pay close attention to the number of people being admitted for diarrhea in each town. When several cases appear in one place, they focus on improving the living environment in that area.

The donation and distribution of proper supplies is also crucial in the fight against cholera. The WHO has set up warehouses full of medicine and rehydration salts in major cities so that even if roads were cut off, they would be able to distribute supplies until the warehouses could be restocked. International aid groups, including Oxfam, Merlin (an agency under the Disasters Emergency Committee (DEC) based in the U.K.), and Concern Worldwide, have delivered tens of thousands of water purification tablets, trucked in clean water, and are attempting to fix damaged water systems. In DMJ, 200 tents were erected on a college campus without any latrines. In response, MSF installed 250 latrines to handle waste there during the last week of August. Diarrhea treatment centers are being set up, which also enables education on disease prevention and the distribution of hygiene kits. The Pakistani military has also been actively establishing relief camps and evacuating those stranded.

Thus far it remains to be seen whether the steps taken by medical teams have been effective in ultimately preventing an epidemic. Tens of thousands of cases of acute diarrheal illness have been reported in the northwest region. Many people die before receiving medical care and, therefore, cannot be diagnosed. Pakistan’s government is responsible for declaring if there is an epidemic or not, and with continued flooding the situation could get worse before it gets better.

More assistance needed

The effort to prevent a cholera outbreak needs to be examined in the context of the entire relief effort in Pakistan, in which the lack of international funding has created its own crisis. As early as August 17, UNICEF announced that if more funding did not arrive, it would not be able to adequately run its clean water program. Pleas for its program continue as of August 25. Although the UN is calling the floods the largest natural disaster in modern history, the amount of incoming aid has been slow and less than that given after other environmental catastrophes. On August 18, Maurizio Giuliano, the Public Information Officer based in Pakistan for the UN Office for the Coordination of Humanitarian Affairs (OCHA), told the U.K.’s Channel 4 Television, “In the aftermath of an earthquake, you know that tens of thousands are dead right away and you see the devastation very clearly. But with a flood where the death toll is only around 2,000, it’s much harder to get people and nations to realize the scope of the disaster.” Shannon Scriber, Senior Policy Advisor for Humanitarian Response at Oxfam America, explains to the Christian Science Monitor that there are other reasons for the slowness of contribution, such as donor fatigue—after donating so much money to Haiti, people are unwilling to give money now.

Another issue is a fear among donors as to what the Pakistani government will do with donor money in a country that many people in the West view as a haven for extremists. In the aftermath of the Haiti earthquake, $742-million was donated in international aid, along with $920-million pledged. Currently, the UN is struggling to raise $460-million for a 90-day emergency period. As of August 25, the U.S. has promised the most, pledging $150-million. The U.K. has committed $100-million along with $45-million from private donors. In a sign of solidarity, Pakistan accepted $5-million from India. However, only close to 70 per cent of the U.N.’s requested aid has been met.

In addition to the issues of funding, the relief effort must be concentrated on innumerable problems at once. While organizations focusing on health have called for more funding for clean water distribution, the Pakistani government recently told the Christian Science Monitor that roads and bridges must be the top priority. On August 18, Feroz Shah, Director General of the National Commission for Human Development of the Pakistani government, explained, “The roads are so important, as without them everything else becomes so much harder. Then comes the food aid, the medical aid, and the revival of agriculture, upon which this region depends.”

Around 20 U.S. helicopters are combating the problem of demolished roads, but the UN has said more are necessary to help. The UN World Food Program needs $150-million to feed six million people for three months, only a fraction of the affected population. Without food, the body’s immune system becomes too weak to fend off illness and cholera could quickly spread through a malnourished population. More doctors are needed to address the increasing health threats, especially female doctors. Additionally, the root causes of the flooding need to be addressed. Rapid deforestation resulted in the riverbanks giving way more easily. There are dykes and levees along the river attempting to contain the water, but these designed were derived from European systems. In effect, they are an improper means of trying to contain the river because they cause silt carried down from the Himalayas that build up in the river. The international community could play vital roles in the rebuilding efforts to ensure that future attempts at containing the river are done properly.

Furthermore, the civilian government has banned charities with Islamic ties for fear they will use the humanitarian crisis as a platform to recruit followers. However, in some areas these groups are the only means of food and water for desperate people. As retired policeman Gul Mohammad Khan told Reuters on August 9 regarding Jamaat-ud-Dawa (JuD), a group with ties to Lashkar-e-Taiba, the perpetrators of the 2008 Mumbai attacks, “We don’t care who they are or what their agenda is. We were in crisis and they were the first to help. That’s it.” The Pakistani government has not been able to adequately meet the needs of millions of people affected and these organizations began filling that gap early on in the flooding. As of August 25, 16 relief camps have been shut down.