In dire straits – The aftermath of rain, floods in Pakistan

Dr. Khalid Mahmood

Pakistan is amongst the countries that are worst affected by climate change. An early summer with extreme temperatures, melting of glaciers and long spells of rainfall, resulting in devastating floods that caused tragedy in the form of death, destruction, displacement, disease and hunger.

More than 33 million people have been affected by the loss of human life and their dwellings, and are now surrounded by flood waters with no escape or place to go. Crops worth billions have been destroyed, set to exacerbate the tragedy in the form of hunger and starvation in the coming year, if not properly dealt with.

People’s homes, hotels, large buildings along riversides and dams were all seen tearing down within minutes alike, by the flash floods. More than 115 districts of the country have been declared calamity-hit, Sindh being the most adversely affected, followed by Balochistan and Khyber Pakhtunkhwa.

There have been enormous financial losses, to the extent of $20 billion. More than 1400 people have lost their lives, along with over 750,000 cattle and livestock since mid-June. Millions of acres of land have been rendered infertile for cultivation for the foreseeable future. Infrastructure, houses, buildings, health facilities and schools have been destroyed – all needing a gigantic will, amount and period for rectification.

Naturally, in this deplorable scenario, numerous health problems have surfaced as additional challenges. Mosquito-borne diseases including dengue fever, malaria and chikungunya are spreading like fire. Water-borne diseases such as gastroenteritis and cholera are already wreaking havoc, expected to be followed by amoebiasis and salmonella infections. Other viral and bacterial infections including respiratory tract infections, eye and skin infections have also been on the rise due to the unhygienic conditions in the camps of displaced flood victims.

According to WHO estimates, 100-400 million dengue infections occur every year, out of which nearly 96 million manifest clinically and the remaining go unnoticed. Pakistan has been having regular epidemics since the floods in 2010, although the reported number of cases is much lesser than the actual number due to improper data collection and record-keeping. Dengue fever causes severe flu-like symptoms that are seldom fatal. It should be suspected in patients with acute high fever of around 40?C, severe headache which also causes pain behind eyes, muscle and joint pains (break bone fever), nausea, vomiting and a skin rash.

These symptoms appear after an incubation period of 4-7 days after the bite of an infected mosquito, and last for 2-7 days. Severe dengue fever is potentially fatal as shock and oblique bleeding can occur, leading to death. There is no specific treatment but early detection, supportive treatment along with consuming plenty of fluids, and avoidance of unnecessary medicines helps. The first dengue vaccine, Dengvaxia, has been approved to be used in 20 countries on people aged between 9-45 years who have already had dengue fever in the past.

Although the number of deaths caused by dengue is not large, it is not insignificant either. The misery of patients suffering from this viral illness is a painful sight. Despite receiving repeated warnings from the public health sector, the concerned government departments have failed to take any proper measures to control the breeding of mosquitoes. Dengue, caused by the Aedes Aegypti mosquito and malaria, caused by the Anopheles mosquito, both spread rampantly in conditions that encourage mosquito breeding in stagnant water. The former also transmits chikungunya, yellow fever and zika infections.

It is not uncommon to find co-infections with dengue and malaria. Multiple families have been found to be suffering from dengue fever and the number of cases is rapidly rising, even in larger cities like Karachi. Hospitals in Karachi are already full to capacity. The situation in interior Sindh and Balochistan is much worse, where health facilities are very meagre.

This year, the prevalence of dengue fever is expected to be much higher than in the previous years because of the intensity of the floods that have displaced millions of people and forced them to live in shelter camps with poor facilities.

Prevention is crucial. Preventing mosquitoes from accessing egg-laying habitats, disposing solid waste properly, covering domestic water storage containers, spraying insecticides on stagnant water in puddles, using personal protective measures to avoid mosquito bites such as nets, window screens, long-sleeved clothes, repellents, coils and vaporizers are all effective measures. Regarding malaria, two tablets of Chloroquine taken per week are known to prevent numerous, even if not all cases, and this recommendation should be implemented by the flood camps for their refugees. Further, improving community participation, mobilizing better control and increasing the number of beds in hospitals are also very essential.

In addition, diarrheal diseases are spreading rampantly, especially in children and infants. The best way to avoid these is to maintain hygiene and drink bottled or boiled water, but that is almost ironic to suggest in the prevailing living conditions of the shelters. However, full efforts should be made to provide them with ORS solutions and sachets. NGOs and to an extent, government authorities are playing their role but considering the magnitude of the problem, large scale efforts are needed to tackle the issue. Similarly, respiratory tract infections in the form of flu, pharyngitis and upper and lower respiratory tract infections are also soaring, requiring proper care, antibiotics and hospitalization in some cases.

There is a shortage of necessary medicines along with eatables in these makeshift arrangements, increasing the morbidity and even the mortality. Red eye and eye infections are also quite prevalent due to poor hygiene and overcrowding, compounding the problems of these poor sufferers. Washing eyes repeatedly with boiled and cool water may be a simple and effective remedy.

Furthermore, the misery of the affected has been multiplied due to ever increasing cases of snake bites. This season of July and August is notorious for snake bites in upper and lower Sindh, where rice cultivation is done and there is a lot of water in the fields. Because of water and heat, the snakes come out of their burrows. Snake poisoning mostly requires anti-snake venom, which is not available in adequate quantities even in hospitals and health facilities, let alone the makeshift arrangements and camps. Even if available in the private market, they are very expensive and not affordable for everyone. This problem of snake bites requires special attention otherwise it can aggravate the morbidity and overall mortality of displaced persons and all those surrounded by flood water.

As a reasonable consequence, the present and aftermath of this huge natural and man-made catastrophe has also created significant mental issues and psychiatric illnesses. The grief of leaving your house, seeing your blood relatives die in front of you and your belongings and livestock being taken away from you in the blink of an eye is unmatched. A significant number of flood victims, especially the women and children, have started suffering from panic attacks, depression, loss of sleep and other similar illnesses. It will be a while before these issues can be resolved, but even then the survivors will continue experiencing psychological problems following the misery and trauma they suffered. It is essential that they receive proper treatment along with psychotherapy, to battle depression, acute stress and post traumatic stress disorders as well as suicidal thoughts.

Lastly, maternal and child health care needs special attention. Many of the pregnant mothers are facing grave difficulties and health issues especially in the refugee encampments – many childbirths have taken place inside too, with no facilities in this regard. Lady doctors are specifically required to serve in these camps to avoid mishaps and improve maternal and child health outcomes.

In sum, our healthcare system has expectedly failed to deliver, despite the scattered, uncoordinated efforts of many doctors. Although, even the health system of developed countries may have shattered in the face of such devastation, it is imperative that we take this catastrophe to re-examine the voids in our own public healthcare system. Seventy-five percent of our population goes to the general practitioners/primary health care and there is an urgent need to improve facilities at that level, beginning with increasing the number of hospitals and beds available within, proportionally to the huge rise in population.