pakistan floods: an unprecedented humanitarian...

© 2010 TASC

Rashid A. Chotani, MD, MPH, DTMDirector, Chemical/Biological Defense Programs, TASCAdjunct Professor , Uniformed Services University Health SystemFormer Director, Global Infectious Disease Alert & Surveillance System (GIDSAS)Johns Hopkins School of Medicine & Bloomberg School of Public [email protected] (Office) 571.642.0549 (Fax)571.425.9730 (Cell)

Pakistan Floods: An Unprecedented Humanitarian CrisisCenter for Global Health, Feinberg School of Medicine, Chicago, ILOctober 14, 2010

http://www.feinberg.northwestern.edu/index.html�

© 2010 TASC

• Health Statistics Before the flood

• Impacts of the Floods

• Global Response

• Additional Mortality

• A Journey Through the Affected Areas

• Discussion

• Conclusions

Outline

2

© 2010 TASC

Pakistan

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Capital: Islamabad

Largest City: Karachi

Official Languages: Urdu & English

Regional Languages: Punjabi, Pashto, Sindhi, Seraiki &

Balochi

Government: Federal Parliamentary Republic

© 2010 TASC

Demographic indicators

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Area in square kilometers 796,096

Total population in thousands 170,294 2010

% Urban population out of total population

35 2009

Crude birth rate 25 2009

Crude death rate 7.7 2009

% Population growth rate 1.7 2009

% Population below 15 years 43.4 2009

% Population 65 years and over 3.5 2009

% Dependency ratio 88.3 2009

Total fertility rate per woman 4.1 2007

© 2010 TASC

Socioeconomic indicators

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Adult literacy rate 15+ years, total (%) 56 2009

Adult literacy rate 15+ years, males (%) 69 2009

Adult literacy rate 15+ years, females (%) 44 2009

Gross primary school enrolment ratio - total (%) 91 2009

Gross primary school enrolment ratio - male (%) 97 2009

Gross primary school enrolment ratio - female (%) 83 2009

Gross secondary school enrolment ratio - total (%) 47 2009

Gross secondary school enrolment ratio - males (%) 55 2009

Gross secondary school enrolment ratio - females (%) 36 2009

Pop with sustainable access to improved water source (%) 93 2007

Population with access to improved sanitation (%) 44 2007

Unemployment in percent 5 2008

Smoking prevalence among adults (aged 15+), total (%) 23 2007

Smoking prevalence among adults (aged 15 +), males (%) 36 2007

Smoking prevalence among adults (aged 15+), females (%) 9 2007

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Health Expenditure indicators

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GDP per capita US$ exchange rate 841 2008

Total expenditure on health (per capita) Average US$ exchange rate

24 2008

Government expenditure on health (per capita) Average US$ exchange rate

7 2008

Total expenditure on health of % of GDP 2.9 2008

General government expenditure on health as % of total health expenditure

29.7 2008

Out-of-pocket expenditure as % of total health expenditure

57.9 2008

General government expenditure on health as % of total government expenditure

… 2008

Ministry of health budget as % of government budget 3.3 …

© 2010 TASC

Human and physical resources indicators Rate/100,000 population

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Physicians 8 2009

Dentists 1 2009

Pharmacists 0.9 2009

Nursing and midwifery 6 2009

Hospital beds 6 2009

Infrastructure - primary health care units and centers

1 2009

© 2010 TASC

Coverage with primary health care services indicators

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Population with access to local health services, total (%) 100 2008

Population with access to local health services, urban (%) 100 2008

Population with access to local health services, rural (%) … 2008

Contraceptive prevalence (%) 48 2008

Antenatal care coverage (%) 100 2009

Maternal care - births attended by skilled health personnel 100 2009

BCG (%) 98

DPT3 (%) 98

OPV3 (%) 98

Measles vaccine (%) 100

HBV3 (%) 99

Pregnant women immunized with 2 or more doses of tetanus toxoid (%)

…

Presenter

Presentation Notes

BCG Bacille Calmette-Guerin OPV3 Three doses of oral poliovaccine, not including supplemental immunization doses DPT3 Three doses of combined diphtheria–pertussis–tetanus vaccine HBV3 Three doses of hepatitis 3 vaccine j Given only to non-nationals k Not included in the national immunization program

© 2010 TASC

Health status indicators

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Total life expectancy at birth (years) 65.4 2009

Male life expectancy at birth (years) 65.2 2009

Female life expectancy at birth (years) 65.6 2009

Newborns with low birth weight (%) 26 2007

Children underweight (%) 37 2007

Perinatal mortality rate per 1,000 total births 56 2004

Neonatal mortality rate (per 1,000 live births) 54 2007

Infant mortality rate (per 1,000 live births) 70.2 2007

Under five mortality rate (per 1,000 live births) 90 2007

Maternal mortality ratio (per 10,000 live births) 276 2007

© 2010 TASC

Selected morbidity indicators

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Annual number (N) of reported cases 2008

Malaria Number of reported cases=121,360

Incidence rate per 1,000 population

= 0.70

Measles Number of reported cases = 441

Incidence rate per 1,000,000 population

= 2.69

Poliomyelitis Number of reported cases = 89

All forms of tuberculosis

Number of reported cases = 267,451

Notification rate per 100,000 population

= 148

AIDS Estimated number of PLHIV = 96,000

Reported number of people receiving ART

= 1,296

Imported cases; rate not calculated

© 2010 TASC

Primary effects– Physical damage - Can damage any type of structure, including

bridges, cars, buildings, sewer systems, roadways and canals – Casualties - People and livestock die due to drowning. It can

also lead to epidemics and waterborne diseases

Secondary effects– Water supplies – Contamination of waters– Diseases - Unhygienic conditions and spread of water-borne

disease– Crops and food supplies - Shortage of food crops can be caused

due to loss of entire harvest– Trees - Non-tolerant species can die from suffocation

Tertiary/long-term effects– Economic - Economic hardship, due to: temporary decline in

tourism, rebuilding costs, food shortage leading to price increase ,etc

Floods Adverse Effects

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Event Death1931 China floods 2,500,000 - 3,700,000

1887 China Yellow River flood 900,000 - 2,000,000

1938 China Yellow River flood 500,000 - 700,000

1975 China Banqiao Dam failure, result of Typhoon Nina

231,000

2004 IndonesiaIndian Ocean tsunami

230,000

1935 Yangtze river flood 145,0001950 Netherland, St. Felix’s flood storm surge

>100,000

1971 North VietnamHanoi and Red River Delta flood

100,000

1911 China Yangtze river flood 100,000

World Deadliest Floods

© 2010 TASC

Over 20 million people affected (>10% of the total population)

– 43% below the age of 15 years– 78 districts out of a total of 121 district– 75% in Provinces of Sindh and Punjab

~ 10 million people without shelter

160,000 square kilometers devastated – Larger than England

Over 2 million hectares of crops lost

Over 1,900 dead

~ 3,000 injured

~ 1.9 million homes damaged or destroyed

~ 1,000 schools damaged or destroyed

~ 200 Hospitals and Clinics damaged or destroyed

Overview of the 2010 Floods: Pakistan

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Floods have devastated villages from the Himalayas to the Arabian Sea

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Affected Areas by Floods: Pakistan

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http://www.pakistanfloods.pk/images/latestmap.jpg�

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Khyber Pakhtoon Khwa: Flood / Rain 2010

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© 2010 TASC

Punjab: Flood / Rain 2010

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Balochistan: Flood / Rain 2010

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© 2010 TASC

Sindh: Flood / Rains 2010

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© 2010 TASC

Flood Damages as of October 11, 2010, by Affected Provinces

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SINDH PUNJAB KPK BALO AJ&K GB Total

Houses Damaged 1,114,629 509,814 200,799 75,261 7,106 2,830 1,910,439

Injured 1201 350 1198 98 87 60 2994

Deaths 234 110 1156 48 71 183 1802

KPK= Khyber Pakhtunkhwa including FATABALO = BalochistanAJ&K= Azad Jammu & KashmirGB= Gilgit-Baltistan

© 2010 TASC

Pakistan 2010 Floods Damages vs. other Major Disasters

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*EstimatesSource:• Post Nargis Joint Assessment report, July 2008, prepared by ASEAN• Earthquake 8/10, Learning From Pakistan’s Experience, prepared by the NDMA, Oct 2007• http://en.wikipedia.org/wiki/Hurricane_Katrina• http://en.wikipedia.org/wiki/2004_Indian_Ocean_earthquake_and_tsunami• http://www.emdat.be/search‐details‐disaster‐list

FLOOD PAKISTAN*

EARTHQUAKE PAKISTAN

KATRINA CYCLONE

USA

NARGIS CYCLONE MYANMAR

TSUNAMI INDIAN OCEAN BASIN

HAITI EARTHQUAKE

Aug-10 Oct-05 Aug-05 May-08 Dec-04 Jan-10

Population Affected 20,251,550 3,500,000 500,000 2,420,000 2,273,723 3,200,000

Area Affected (Sq Km) 160,000 30,000 N/A 23,500 N/A 13,226

Deaths 1,967 73,338 1,836 84,537 238,000 230,000

Injured 2,865 128,309 N/A 19,359 125,000 300,000

Household Damaged 1,884,708 600,152 200,000 450,000 N/A 250,000

© 2010 TASC

Many markets have been destroyed, and food is generally not available

Nearly 8 million acres of agricultural land have been flooded

The main water sources in the area are dug wells, hand pumps, and a few tube wells which have become contaminated, and the water is no longer safe to drink

Food and Water

21

People can live on small amounts of food, but they can’t survive without potable water

© 2010 TASC

Many displaced families are without shelter

Others have found temporary shelter with friends and relatives, but overcrowding is making water, food, and sanitation even more inaccessible

Many schools, both private and public, are now serving as temporary shelters

Shelter

22

Overcrowding conditions will lead to spread of communicable diseases

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Some clinics in the area have been washed away, and medical staff and medicine are scarce– ~200 hospitals & Clinics damaged/destroyed

Children and families are suffering from diarrhea, vomiting, malaria, and acute respiratory infections

Prior to the flooding there was lack of proper toilets in homes

Since the flooding, human waste has been mixed with drinking water

In addition, water is sitting stagnant in many places, increasing the risk of disease

Health and Sanitation

23

Major risk of waterborne disease outbreaks, e.g., cholera, typhoid and increased incidence of malaria

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Road infrastructure in affected areas is destroyed

Many isolated communities are depending on items ferried in by helicopter to survive

Power is completely out in some areas and there is power-shedding across the country

Infrastructure

24

Destruction of roads and lack of power plants will further hinder aid & devastate the economy

© 2010 TASC

Most people are farmers, earning a living from crops and livestock

Millions of acres of crops have been damaged, as have irrigation systems

Livelihoods

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Farmers are likely to remain dependent on aid until well into 2012

© 2010 TASC

Response to Pakistan Floods

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National and international communities has launched the immediate response to the affected people in Pakistan

However, there are difficulties during disaster responses:– Billions of dollars are needed– Inaccessible or hard to reach

areas, as the roads are destructed and lands are submerged by floods water

– Political relationship affects providing or accepting the relief aids

– Donors are concerned whether the funds will reach Taliban instead flood victims

Security issues

Unexploded mines

© 2010 TASC

United Nations and its partners have launched a revised Pakistan Floods Emergency Response Plan

– Over US$2B to provide aid for up to 14M people over a 12-month period

The appeal has 483 projects to be carried out by – 15 United Nations bodies, the International Organization for

Migration (IOM), and 156 national and international non-governmental organizations (NGOs)

The appeal includes the earlier amount of $459.7M, requested on 11 August

The initial appeal of $459.7M is 80% funded, making the unmet requirements for this emergency $1.6B

TOTAL COMMITTED by World = $1.85B– Administrative Agency UN/INNGO - $1.22B – GoP – $6.34M

Major Donors:– SA (Gov + Others):$362M; US:$360M; EU: $187M; Turkey (Gov +

Others): $176M; UK $117M; Iran 101M; OTHERS

Response to Pakistan Floods

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The size of the revised appeal reflects the enormous human and geographic scale of the catastrophe, and the necessity of putting into place the right kind of early recovery, including

projects in agriculture, community restoration, education, health and shelter

http://www.reliefweb.int/rw/rwb.nsf/db900SID/VDUX-89DTJ3?OpenDocument�

© 2010 TASC

Ensure all assessments and response efforts take into consideration the needs of: – Women of childbearing age– Pregnant women– Children– Elderly– Disabled

The Most Vulnerable Victims

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© 2010 TASC 29

An estimated 400,000 women in the affected population are pregnant with 45,000 deliveries per month, many of which will be in an unsafe environment

without access to a skilled birth attendant, an adequate referral system,

and emergency obstetric care. About 4,500 women will need access to

emergency obstetric services

© 2010 TASC

Population <15 years (43.4%) = 9,000,000

Population b/w 16-64 years (52.3%) = 10,300,000

Population 65 + (3.5%) = 700,000

Total Affected Population = 20,000,000

Guesstimating Additional Mortality

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Assumptions

~50% female = 5,150,000~30% childbearing age = 1,545,000~25% expecting mothers = 386,250

© 2010 TASC

Guesstimating Additional Mortality

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N=386,250 Expecting Mothers

Health Indicators

Rate Deaths/Year Deaths/3 months Excess Deaths due to Floods

10% 20% 30%

Maternal Mortality Rate

276/10,000 Live Births 10,661 2,665 266 533 800

Prenatal Mortality Rate

56/1,000 Total Births 21,630 5,408 540 1,081 1,622

Neonatal Mortality Rate

54/1,000 Live Births 20,858 5,214 521 1,043 1,564

Infant Mortality Rate

70.2/1,000 Live Births 27,115 6,779 678 1,356 2,034

Under 5 Mortality Rate

90/1,000 Live Births 34,763 8,691 869 1,738 2,607

TOTAL 115,027 28,757 2,874 5,751 8,627

3,000 to 9,000 excess deaths in expecting mothers, prenatal, neonatal, infants and <5 years old due to the

floods in affected population

© 2010 TASC

http://storyhub.actionaid.org/pages/view.php?ref=86922&search=!collection22618&offset=48&order_by=relevance&sort=DESC&archive=0&k=�

© 2010 TASC

http://storyhub.actionaid.org/pages/view.php?ref=38508&search=!resource38508&offset=0&order_by=relevance&sort=DESC&archive=0&k=�

© 2010 TASC

Presenter

Presentation Notes

Why is Pakistan vulnerable to flooding? The Indus River system provides water for one of the largest irrigated areas in the world. Regular flooding improves the fertility of the soil, so people can grow more food. Communities are prepared for regular flooding and have local and traditional organisations to deal with floods. It is the scale of the recent flooding which has destroyed lives and livelihoods. Flood risk can be reduced by building levees (embankments) along the river. These act as barriers which prevent the river from bursting its banks in extreme floods. But, the Indus River is full of sediment that causes the river channel to silt up and can make the river even more prone to flooding. The problem has been made worse by deforestation. Trees protect the headwaters from erosion, but over the past half century, more sediment has been flushed down the rivers as forests have been cut. More information at http://www.bbc.co.uk/news/science-environment-10958760 Photo: Upper Swat, Khyber Pakhtoonkhwa, Pakistan 5 August 2010/ActionAid

http://storyhub.actionaid.org/pages/view.php?ref=86472&search=!collection22618&offset=96&order_by=relevance&sort=DESC&archive=0&k=�

© 2010 TASC

The ongoing floods in Pakistan have resulted in a critical need for health services for the affected population which even prior to the crisis had limited access to services

The inadequate health infrastructure, coupled with large scale population displacement forced by the floods means an increased risk of diseases and disabilities

Large numbers of people are being exposed to public health risks exacerbated by inadequate sanitation, compromised safe water supply, and food shortages

More than 20 million Pakistanis have been affected, out of which 10 million are in need of immediate humanitarian assistance-including an estimated 1.5 million women of childbearing age with 400,000 potentially pregnant

– Resulting in 3,000 to 9,000 excess deaths in the last three months alone among expecting mothers, prenatal, neonatal, infants and <5 years old

Pakistan has a high burden of infectious diseases

Poor and marginalized populations living in unsafe dilapidated living conditions in the IDP camps/in makeshift shelters and flood affected areas are disproportionately affected

Discussion

82

© 2010 TASC

Cases of acute watery diarrhea, cholera, typhoid, acute respiratory illnesses, malaria, dengue, measles, skin disease/disorders etc will continue to escalate and some will cause major outbreaks

The pre-existing high rate of chronic malnutrition in children (30-35% are stunted), combined with food insecurity and increased risk of disease, threatens to substantially increase the numbers of children with acute malnutrition

Patients with chronic diseases, such as TB, diabetes and cardiovascular diseases, HIV, face treatment interruption with consequential health risks

– One in three adults over the age of 45 years suffers from high blood pressure; and 10% have diabetes

– HIV/AIDS is a significant problem, with a concentrated epidemic among injecting drug users – HIV prevalence in this group has been reported to be between 10% to 20%

The health workforce has been affected by the flooding– At least 35,000 Lady Health Workers (LHW) have been displaced

Management capacity of the local health systems in the flood-affected districts has virtually collapsed

Discussion

83

© 2010 TASC

The district health authorities are currently not able to cope with the impact of the disaster

Approximately over 70% of the total health expenditure is from direct out-of-pocket payment and there is no functional social security system

The affected population has lost livelihoods and is unable to pay for health services

Following a disaster of this magnitude and severity, mental health problems are expected to increase

Discussion

84

© 2010 TASC

Pakistan's development prospects have been disrupted for many years

The damage to the economic infrastructure and livelihoods is immense

Irrigation, drainage and storage facilities are badly affected

Farmers who lost their crops and who are not able to plant their fields by November are likely to remain dependent on aid until well into 2012

Hundreds of thousands more lost their shops or other small businesses

Conclusion

85

United Nations estimate aid will be required for at least 2 years before Pakistan returns to its current degree of development

© 2010 TASC

Strong component of success will be

– Actual aid versus the pledges

– Sustained international assistance

– Political stability in Pakistan and the region

– Identifying the needs of the affected population

– Appropriate aid getting to the affected in a timely fashion

– Providing appropriate shelter and security

– Availability of skilled HCW

Discussion

86

© 2010 TASC


– Provision of essential medicines and supplies including for life threatening communicable diseases, non-communicable and chronic diseases

– Basic emergency health services, including maternal and newborn/child health services (delivered through community-based services, mobile teams, static units and referral facilities)– Diarrhea Treatment Centers functioning in all affected districts– Under five year vaccinations against measles and polio, and vitamin A through

emergency mass vaccination campaigns– Delivery of preventive and curative malaria activities in all the endemic areas in

the affected districts

– Mental health care

– Scaling up of surveillance and the early warning system of epidemic prone diseases in all the affected districts

Discussion

87

© 2010 TASC


– Managing the many national and international humanitarian health NGOs in the affected areas by strengthening of the local authorities’ governance role to avoid uncoordinated interventions that may undermine the future recovery of the health system

– Solutions with partners to remove financial barriers to enable access to services for at least as long as the humanitarian phase lasts

Discussion

88

© 2010 TASC © 2009 TASC89

UN Secretary-General Ban Ki-Moon

"I will never forget the destruction and suffering I

have witnessed”

“In the past I have witnessed many natural

disasters around the world, but nothing like this."

pakistan floods: an unprecedented humanitarian...

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