January 30, 2011

Pakistan 2010 © Jean-Marc Jacobs

A man makes his way through the floodwaters in Nowshera.

At first, the flooding that began this past July in Pakistan was said to have affected tens of thousands of people in the northeast. Then the water began to spread south and west and the numbers grew. Hundreds of thousands were impacted, it was reported, then one million, then five million, then ten. Eventually, the number of people whose lives were uprooted reached an astonishing 20 million in all four of Pakistan’s provinces—Khyber Pakhtunkhwa (KPK), Balochistan, Punjab, and Sindh—as well as the Federally Administered Tribal Areas (FATA) and Kashmir.

As the monsoons rains fell, rivers rose precipitously, destroying bridges and roads and stranding people on newly created islands. “The devastation [caused] by the floods is enormous, and some towns have been completely washed away,” said Josep Prior Tio, MSF’s field coordinator in Swat.

Pakistan 2010 © Ton Koene

 

Shelter from the elements—hard rain, stifling heat, fierce winds—was scarce. Schools and public buildings became ad hoc displacement camps for those with nowhere else to go. “In the first few days of the flooding, there was a mass movement of people, which was terrible to witness,” said Dr. James Kambaki, MSF’s project coordinator in Balochistan. “People were on tractors, on ox carts, on donkey carts, on motorbikes, on tuk-tuks, and on foot, picking up anything to cover themselves.” It quickly became difficult for many to find food to eat or safe water to drink.

Valuable Past Experience

MSF has been providing health care in Pakistan since 1988 and was running several projects in the north before the floods arrived. In Balochistan, MSF was active in Dera Murad Jamali, in the border town of Chaman, and among the Afghan refugees living in Kulchak; in the districts of Peshawar, Malakand, Mansehra, Hangu, and Dir in KPK; and in FATA’s Kurram agency. The organization provided primary and secondary health care to people who had scant access to either, along with obstetric and maternal care, nutrition programs, surgical and post-operative services, pediatrics, and treatment for chronic diseases. It responded to cholera and leishmaniasis outbreaks and natural disasters such as the 2005 earthquake in Kashmir and previous flooding in Balochistan. And it assisted the more than two million people displaced by fighting between the Pakistani military and insurgent groups.

Staff had grown accustomed to the challenges of working in the country, particularly the large-scale population movements, the lack of services, and the security concerns that affected the mobility of both patients and MSF personnel. Nevertheless, MSF was able to tend to hundreds of thousands of people in some of the poorest regions of the country last year, and was well situated to respond again.

MSF, in essence, followed the floodwaters, tending to those in their wake. The effort began with exploratory missions to assess needs in the districts of Swat, Lower Dir, Malakand, Peshawar, Nowshera and Charsadda in KPK, along with the Nasirabad and Jafarabad districts in Balochistan, and proceeded later into Punjab and Sindh. In some instances, the impact was immediately evident. In others, especially where roadways and bridges had been destroyed, it took longer to identify the needs.

Pakistan 2010 © Massimo Berruti

 

At the height of its flood response, MSF had 160 international staff and more than 1,500 Pakistani staff supporting hospitals, treating injuries and illnesses—particularly malnutrition and acute diarrhe —running mobile clinics, and distributing hygiene kits, cooking sets, plastic sheeting, and tents. They also trucked in safe drinking water in order to prevent the spread of waterborne diseases, such as cholera.

MSF provided general care along with specialty care, adapting its work to the circumstances. Take maternal care, long a staple aspect of MSF’s operations in Pakistan: “In June, we dealt with 13 complicated deliveries and performed 4 complicated C-sections” said MSF obstetrician, Dr. Linnea Ekdahl. “Now after the floods, in the month of September, we have seen 79 women facing complicated deliveries and performed 10 complicated C-sections.”

Rain Lets Up , Conflict Does Not

By October, the rain had abated, and the waters had, for the most part, receded. In the north, people began returning to their villages to salvage what was left of their homes. In KPK, said MSF Country Representative in Pakistan Thomas Conan, the nutrition situation was stable and disease outbreaks had been controlled. Water distribution was handed over to other actors, Diarrhea Treatment Centers were closed, and the number of projects in the province returned to pre-flood numbers. But even into December, teams were providing flood-related medical care, water and sanitation services, and distributions in Sindh, where the water was slower to recede. And MSF opened a new base to serve flood-affected communities seeking refuge in Karachi.

All told, through the end of November, MSF had conducted 80,150 consultations as part of its emergency flood response, treated more than 4,500 malnourished children, distributed a total of 64,836 relief item kits and 16,300 tents, and built 843 latrines. Expenditures for the emergency (also through the end of November) stood at $12.33 million. (MSF’s 2010 budget for regular activities in Pakistan is approximately $11.28 million.)

The task of rebuilding and recovering is an immense one. Thomas Conan said nutrition would have to be watched long-term because the fall harvest was ruined for many farmers and the next one was jeopardized by damage to their fields. Additionally, he added, as winter arrives, “the population still will not have shelter,” particularly in the north, “or proper access to quality primary health care.” MSF is therefore still distributing materials to build transitional shelters and running mobile clinics and nutrition centers for affected populations in southern Sindh.

Pakistan 2010 © Andrew McConnell

Mothers and their children are tended to in Sindh.

Furthermore, the end of the rains has not meant the end of other serious issues. “The conflict existed before the floods and the conflict is still present after the floods,” Conan said, and there is still “a deficit of capacity in terms of primary and secondary health care for the population.” In KPK and FATA, where fighting has been a constant for the last five years, “we are the only organization with surgery capacity for some one million people.” There is still a yawning divide between the needs on the ground and services offered by governmental and non-governmental organizations. “It’s part of MSF’s responsibility, if not to speak out, then to point out that these populations are still in need,” he said.

Politicization of Aid

An additional concern was the politicized nature of the flood response discussion, one that officials from several countries, including the United States, linked to national and security interests. Christopher Stokes, MSF’s General Director in Belgium, addressed this in an op-ed on Foreign Policy magazine’s website. “Barely hidden beneath the surface of Pakistan’s worst flooding in living memory were the geopolitical stakes shaping both the justifications for official Western assistance and how aid was delivered to victims of the disaster,” he wrote. “The perverse result may be a further restricting of the ability of humanitarian aid workers to assist the Pakistani population in the most volatile areas of the country.”

He continued: “Winning the trust of all parties in a conflict and gaining access to the affected population depends on being understood as purely humanitarian— that is, not taking sides but delivering aid based on need alone regardless of political or other influences.”

The worry on the medical front is that the impact of the floods lingers, and that the conflict continues to injure, kill, or drive from home civilians who cannot escape the theater of war. The concern on the political front is that the ability to independently and impartially deliver crucial medical aid will be undermined by decisions taken in faraway capitals. “This,” Stokes concluded, “may ultimately jeopardize our ability to provide assistance to populations trapped in one of the most volatile and neglected regions in the world.”