Drought and flooding could lead to bonded labor in Pakistan

When Muhammad Yunus began his micro-credit Grameen Bank in the 1970s it was in response to the unfair practices of moneylenders in his native Pakistan. The moneylenders would loan money to the poor at high interest rates. If the poor couldn't repay, they would become bonded laborers for the moneylenders.

The problem still exists today, but something has since changed to make it harder for the poor to repay... the effects of climate change. The poor farmer would hope that a good crop would give him enough money to repay the loans. Now repeated floods and droughts have doomed more poor farmers into default.

From Reuters Alert Net, writers Saleem Shaikh and Sughra Tunio describe the how the fortunes have changed for many farmers.  

“Because,the agriculture and livestock farming families were still recovering from the heavy damages (caused by last's year's devastating rains) to crops and livestock, this year's drought conditions have multiplied economic and health miseries and sufferings of these pastoral and nomadic families,” said Ali Akbar Rahimo, executive director of the Association for Water, Applied Education and Renewable Energy (AWARE), a not-for-profit local NGO in Tharpakar and adjoining districts.

Tharparkar’s deputy commissioner, Tahir Memon, said this year’s drought has left many families with massive financial losses, particularly if their loans came from private moneylenders.

Generally, farmers procure fertiliser, seed and other farm inputs on credit each year from local moneylenders and sell some of their crops to clear their loans if there are good rains. Those who cannot often default, and many defaulter families end up in bonded labour at brick lins, or working in factories, shops,  or the houses of moneylenders.

Because of the absence of formal government-run lending facilities, most farming families in Tharparkar district are at the mercy of moneylenders, whose inflated interest rates can keep poor families trapped in debt for decades. 

Drought in Tharparker is also worsening health problems in the district, as people and animals too weak to migrate turn to drinking contaminated water, officials said. Pregnant women and young babies are particularly hard hit.

Another unresolved crisis: the Pakistan flooding

The floods in Pakistan last year destroyed over 1.5 million homes. A great percentage of the flooding victims are still homeless to this day. Aid organizations have been hampered in their efforts because of spy wars between the US and Pakistan. The wars have escalated since the death of Osama Bin Laden as Pakistan tries to stop any CIA activity in the country.

From the Guardian. writer Declan Walsh describes another long past crisis that remains unresolved.

With millions of flood victims still in urgent need of aid, western charities say their efforts are being hit by the fallout from Osama bin Laden's death as the government hunts for CIA spies. Stringent visa regulations and restrictions on movement by the military are causing long delays, increasing costs and affecting the delivery of aid to areas hit by floods and the conflict with the Taliban.

Last month a young American aid worker with Catholic Relief Services was brought to court for visa irregularities, imprisoned for nine days, then deported. British agencies say their staff have fallen under the microscope of Pakistan's spy service, the ISI, with officials visiting field offices and introducing restrictions on travel.

"We've seen gradual restrictions on movement and longer processing time for visas," said a spokesman for the Pakistan Humanitarian Forum, which represents 40 aid groups.

The crackdown started after CIA agent Raymond Davis shot and killed two Pakistanis in Lahore last January, and intensified after the killing of Bin Laden in Abbottabad on 2 May.

Aid workers in Sukkur, a southern city at the heart of flood relief efforts, started to complain of regular visits from intelligence officers and police. In Jacobabad, location of a sensitive airbase, agencies were told that visiting certain areas now required a "no objection certificate" – an official letter of permission.

"The authorities have started paying more attention to who is in the country and what they are doing," said Michael O'Brien of the Red Cross.

Unsafe water kills 250,000 children a year says the Pakistan government

From IRIN, a story about unsafe water in Pakistan. A new survey finds that 83 percent of the country's water is unsafe to drink.

After several weeks of severe sickness, with unrelenting diarrhoea and high fever, Shamshad Ali, aged five, from a village near the town of Sheikhupura in Punjab Province, finally feels strong enough to venture out of his house again.

“For a few days, when he was really sick and weak and could not even keep liquids down, we thought we might lose him. We were terrified because last year my cousin lost a four-year-old daughter to diarrheoa,” Shamshad’s father, Muhammad Akhtar, 32, told IRIN.

Shamshad, who is now back in school, has been fortunate. According to a new study by the Pakistan Council of Research in Water Resources (PCRWR), a government body, details of which have appeared in the media, 82 percent of water sources tested in 24 (of the country’s more than 100) districts across all four provinces, provided water that is unsafe to drink.

The report, which has yet to be formally released, is based on a five-year study and notes that 250,000 children die in the country each year as a result of diarrhoeal disease originating from impure water.

PCRWR Chairman M. Aslam Tahir told the media the study was “comprehensive” and that he did not need to make further comments. Previous studies have also found poor water quality in urban centres.

“The findings seem to be accurate. Due to policies over past years, there has been widespread contamination of water sources. Poor governance adds to the problem and people are basically helpless,” Khalid Hussain, an Islamabad-based expert on water issues, told IRIN.

Water filtration

He also said the problem could be solved only by “adopting indigenous methods”.

Indigenous methods have been devised and are being used, but on an extremely small scale. Sindh-based NGO Association of Humanitarian Development, has been using a simple filtration system using two clay pots in the province.

Khursheed Bhatti, head of the organization, told IRIN: “We have developed this method as a cheap, indigenous way to filter water. Up to 15 litres of water a day can be cleaned in this way.” Larger NGOs have shown interest in the unique filtration technique, which has been used for over three years in Sindh.

Water boiling

Poverty and a lack of awareness on the part of people add to the issues involved in accessing safe water. “We know we should boil the water we collect from a hand-pump for at least 15 minutes, but how can I manage this when all I have is a tiny kerosene stove with one burner?”, asked Uzma Bibi, who lives in a village 50km from Lahore.

A mother of four, she added: “I must also prepare food daily for a household of nine on the same stove, and fuel prices are rising so sharply we can barely afford to keep the flame burning except when it is essential for cooking.” The prices of petroleum products have risen several times over the last few months triggering angry protests earlier this year.

“Even now there are people who do not boil water because they are unaware it is a principle source of disease. I see people suffering from conditions caused by unsafe water almost every day,” said Rubina Ijaz, a paediatrician in Sheikhupura. She said infants and small children were often the worst sufferers, as mothers who were not breast-feeding frequently “mixed dry formula with water that was not safe” resulting in sickness.

According to experts, growing water scarcity adds to the problems associated with the availability of safe water in the country.

“All my three children suffer from diarrhoea every now and then. Doctors say water is responsible, but it is not easy to locate safe water, or to boil and then cool it in summer. After all, we have no refrigerators,” Shamshad’s mother, Sadiqa Bibi, said.

Vicious circle of fluoride contamination, illness and poverty in Pakistan

From IRIN, a story about contamination of water sources in Pakistan.

Tharparkar in Pakistani’s Sindh Province relies heavily on underground water sources because it has no rivers, but fluoride contamination is proving a major source of illness, experts say.

“The worst affected villages are Samoon Rind, Kalario, Narovari and Sukhani," Iftikhar Ahmed, a researcher from Dow University of Health Sciences (DUHS) said. "In Samoon Rind alone, of the 950 residents, over 300 are suffering from dental and skeletal fluorosis.

"We carried out multiple tests on them to rule out any genetic disorder," he added. "Combined with poor nutrition and hygiene, the population is very vulnerable.”

A high fluoride intake causes dental and skeletal fluorosis, osteosclerosis, thyroid and kidney problems. It also leads to irreversible chronic bone and joint deformations.

A joint study in 2010 by DUHS, the Pakistan Council for Scientific and Industrial Research (PCSIR) and a local NGO Association for Water, Applied Education & Renewable Energy (AWARE) - found over 80 percent of groundwater in the district unfit for human consumption.

“Over the course of research carried out here in Thar [Tharparkar], we mapped all over the district," said Ahmed, who has been studying the problem for the last few years. "While the normal fluoride level in water is supposed to be 1ppm, in many locations here it is as high as 13ppm, making it unfit for human consumption.”

Another study conducted by AWARE entitled Underground Water Quality of Thar: A Detailed Analysis 2003-08, found more than 50 percent of the population using water with total dissolved solvents of over 5,000 mg per litre (mg/l). In one village in Naroowari, that figure rose to 20,000 mg/l, well over the World Health Organization's maximum limit of 1,500 mg/l.

Tharparkar District had an estimated population of 1.23 million in 2008. It receives an average annual rainfall of only 100-300mm, hence the dependence on underground water.

Poverty

Ali Akbar Rahimoo, executive director of AWARE, called for desalination projects and awareness-raising.

“What we need here are desalination/fluoride ion removal plants," he said. "AWARE has installed windmills to get water from deep underground, and small plants for desalination and removal of fluoride in different villages, but that is still not sufficient.”

However, two desalination plants set up by AWARE in Sanjwani and Samoo Rind lie abandoned for lack of money to buy the fuel to run them.

“The communities here are poor and cannot pool enough money to run these facilities," Rahimoo told IRIN. "The federal and provincial governments must take the problems here into account.”

He added: “The 'talukas' [sub-districts] of Umarkot, Chachroo and Mithi are severely affected by fluoride contamination. Although deeper wells are a possible solution, the people lack the resources for digging and maintaining these installations.

"Furthermore, it would add to the burden of women as they are the ones who have to fetch water as they have to pull the rope over a long distance and will have to wait for longer to get the water out. Solar pumps can be very helpful in this regard but again, cost is an issue. We are working on a project of rainwater harvesting but again, that is very much dependent on the amount of rain received.”

Deformities

Locals say cases of deformities are affecting families.

“My daughters are beautiful girls but they have been rejected multiple times for marriage because they look ill and have bad teeth," said Mohan,* a middle-aged schoolteacher from Malo Bheel, a town 55km from Mithi. "I am ready to give good dowry but before that I wish I could do something about the yellow teeth and weak bones...

"My eldest daughter has given birth to sons both of whom are deformed."

The daughters and grandsons, a local doctor said, suffer from arthritis and are either victims of fluorosis or a genetic disorder.

“No one in my family had such weak bones and hunched shoulders," Mohan explained. "When the doctors told me that it is the water in our wells that is responsible, I realized it could be something in the water. Over the years, the water has turned more brackish and muddy, and I feel that we are consuming poison knowingly.

"I just hope and pray that no child in my family is ever born with this deformity [again].”

Guest Voices: Floods in Pakistan Expose Poverty and Malnutrition

Next up for our series of posts from Concern Worldwide is a story about Pakistan and their recovery from last summer's flooding. Writer Mubashir Ahmed serves as Concern's Assistant Country Director for Pakistan. He says that once Concern arrived to help out after the flooding they found deeper ongoing conditions of poverty that is fueled by a tenant farming system.

Last summer’s massive floods swept through and destroyed lives, houses, crop lands and road infrastructure, causing enormous suffering and damages across an area the size of Italy. The disaster has drawn a significant emergency and recovery response on the part of numerous International NGOs, taking them to often remote areas where any kind of aid had been sparse for many years.

What Concern Worldwide and its fellow aid organizations discovered—aside, of course, from communities’ grave needs in the wake of the floods—were chronic conditions of poverty, malnutrition, poor health, as well as—especially in Sindh Province—inequitable conditions for tenant farmers and laborers. Most of the flood affected areas where we are working today were already very poor and vulnerable before the floods, and ranked low on the United Nations Human Development Index.

Tenant farmers work very hard for very little and are trapped in an archaic feudal system. The landlords benefit much more from the land than their tenants. Seasonal tenants are paid only a third of the profit gained from the harvest, and they have no rights or formal relationship with the landowner—who is often an absentee landlord—once the harvest is over. Attempts have been made at land reform on several occasions since the foundation of the state, but a lack of political will made these efforts ineffective.

There have been widespread accusations of diversion of flood water by influential figures during the 2010 floods, as reported widely in the national and international media[1]. Pakistan’s Supreme Court has constituted a judicial commission to investigate the breaching of dykes in Sindh by influential landowners to save their farms.

Children are the major victims in all this. That becomes evident when you examine malnutrition rates. Lack of proper nutrition has been a problem in Sindh for some time and the situation was exacerbated by the floods—stored food, standing crops and agricultural inputs like seed and fertilizer were destroyed in the deluge.

A UNICEF report, entitled “Children in Pakistan: Six Months After the Floods,” quoting the data by the Sindh De­partment of Health, indicates malnutrition at or beyond emergency threshold levels, with a Global Acute Mal­nutrition (GAM) rate of 23.1% in Northern Sindh and 21.2% in Southern Sindh. The WHO gives 15 per cent as the emergen­cy threshold level to trigger a humanitarian response. The same report referring to records from Northern Sindh has revealed a Se­vere Acute Malnutrition (SAM) rate of 6.1 per cent. These figures are on a par with what NGOs have been confronted with during the most severe nutrition crisis in Africa.

I am cautiously optimistic that the spotlight put upon the country’s very poorest people will have long-term beneficial effects. But the task at hand is staggering.

[1] Daily Express Tribune, Islamabad (Jan 16, 2011); BBC News, South Asia (Sep 2, 2010); The Telegraph Pakistan (March 19, 2011)

Video: Swat road links being restored

From Al Jazeera, a video on the effort to restore bridges that were destroyed in last year's Pakistan flooding.

Pakistan floods uncover evidence of feudalism’s impact on poor

From IRIN, a story about how the Pakistan flooding uncovered a tribal feudalism that contributes to poverty.

The floods that swept across vast tracts of land from July to September 2010 covered many fields, houses and roads in a sea of swirling water - but they also played a part in exposing the depth of existing poverty and deprivation in Pakistan.

“The malnutrition we are seeing is not new. It has nothing to do with the floods; it is just that we are seeing it now as people come into contact with medical teams,” Shershah Syed, a gynaecologist who has devoted himself to caring for impoverished women requiring care during pregnancy and birth, told IRIN.

Some of the ways in which powerful feudal families - in many cases linked to the political and bureaucratic elite - acted to protect their own interests at the cost of ordinary villagers have been well documented. Feudal overlords have been accused, both in the southern Punjab and in Sindh Province of influencing decisions regarding the diversion of floodwater or the breach of over-flowing dams to protect their own land.

A judicial investigation continues into allegations that in other places protective dykes were breached by wealthy landowners to save their farms, while flooding those of impoverished - and powerless - villagers.

The more subtle ways in which Pakistan’s feudal system works against people, even in times when there is no natural disaster, are beginning to surface only now - in some cases as a result of surveys conducted to assess the plight of flood-affected people.

Vast estates belonging to feudal families stretch out across the country, sometimes covering hundreds of acres. According to the World Bank, about 2 percent of households control more than 45 percent of the total land area. Large farmers have also monopolized subsidies in water and agriculture - with the system in place contributing heavily to rural poverty, the Bank says.

Call for land reform

“In a country where about half the workforce is engaged in agriculture, the key to improving lives is an end of feudalism by implementing effective land reforms. No one should own more than 12 acres [4.86 hectares] of agriculture land,” Farooq Tariq, spokesman for the Labour Party of Pakistan, told IRIN.

“Throughout Pakistan, millions of peasants are working on land they do not own, giving between half and two-thirds of their crops to landlords. The poor peasants and landless agricultural workers are exploited in many ways. Workers often end up tied to the land, after taking a loan from a landowner and offering to pay it back by working. Sometimes whole families end up in this type of debt bondage, working to pay off a loan on which the interest keeps accumulating. This system is one of the many ways that ties the peasants to absolute poverty,” he said.

Historically speaking, land reform has been held back by the fact that many parliamentarians are themselves big landowners, and as such are unwilling to initiate a re-division of land.

Nutritional crisis

The impact of feudalism, and the poverty it gives rise to, is poorly documented, but six months after the most devastating floods in the country’s history, with Sindh Province worst hit, a provincial government report based on a survey conducted with UN Children’s Fund (UNICEF) support, has revealed a grave nutritional crisis. The survey has found a global acute malnutrition (GAM) rate of 23.1 percent in children aged 6-59 months in flood-affected areas of northern Sindh and 21.2 percent in southern Sindh - rates above the World Health Organization’s 15 percent emergency threshold level.

A severe acute malnutrition (SAM) rate of 6.1 has also been uncovered in northern Sindh, with the Sindh government estimating about 90,000 under-five children are malnourished.

According to UNICEF, SAM is an advanced state of acute malnutrition. Children with SAM need immediate treatment and are 10 times more likely than healthy children to die before they reach their fifth birthday. The survey also found high levels of malnutrition among women.

Experts working in the field, however, believe this situation is a product of entrenched deprivation, rather than floods.

"The malnutrition [revealed by the survey] was not caused by floods but by poverty; the majority of IDPs [internally displaced persons] in camps are from the lowest quintile of poverty", Andro Shilakadze, a senior UNICEF field officer in Sindh, told IRIN.

“The women of Sindh have suffered like this for thousands of years due to the feudal system in the province, and of course the mother’s health affects the child,” said gynaecologist Syed, who has performed life-saving operations in the most primitive conditions across flood-hit parts of Sindh and also runs a flood-relief camp.

Women eat last

“It is simple actually. Women work hard in the fields and in their homes. They receive only what is left of the food after the rest of the family has eaten. Men are served first, then the children and then the women last of all,” she added.

“It has always been like this. We women eat last, because we are least important,” Sumundri Bibi, an emaciated mother of six, told IRIN at a flood-relief camp in the southern Sindh town of Thatta.

“This is a patriarchal culture. Women suffer due to it,” Syed said.

James King’ori, nutrition cluster coordinator for UNICEF, told IRIN from Islamabad: “Women, particularly of child-bearing age (15-49), have an increased nutritional requirement to not only maintain their body growth, enable daily chore undertaking but also to support pregnancy and breastfeeding of infants. Addressing poverty in a strategic manner to benefit women is key,” he said.

But this seems unlikely to happen until there is a break from the system of uneven land ownership, and the exploitation that comes with it. “Ownership of land can quickly break the poverty cycle. We have seen examples of this in places where tenant farmers have taken control of land,” Tariq said.

“I know nothing about land ownership - just that we struggle to feed our children, and eat less ourselves so they have more on their plates,” Sumundri said.

A possible water scarcity crisis in Pakistan

While the water from last year's flooding in Pakistan is still drying up, the country could face another water related problem in not having enough. The flooding did extensive damage to irrigation and sewage facilities that were already in poor shape before the flooding. Experts warn that if repairs are not made quickly Pakistan could see severe water shortages within 25 years.

From the Inter Press Service, writer Timothy Spence has this anylasis of the Pakistan water problem.

"There are so many other priorities that the government is facing, particularly at a national security level, and to be frank, Pakistan’s government has never really made genuine, sustainable commitments to human development and human security issues, such as guaranteeing better access to water for the masses," says Michael Kugelman, an Asia analyst at the Woodrow Wilson International Center in Washington.

A Woodrow Wilson Center report titled ‘Running on Empty’ that Kugelman oversaw in 2009 warned that Pakistan’s water situation is "extremely precarious" and that the South Asian nation could face widespread shortages within 25 years. He said last year’s floods exposed the government’s neglect of infrastructure, including dams, "one of the big manifestations of the water management policy failures."

"I think you could argue quite conclusively that if repairs had been done in a more timely fashion or more efficaciously in the last few years, that the damage from the flood would not have been as extensive as it was," Kugelman told IPS.

Aid officials say restoring water and sanitation services - already inadequate before the inundations - remain a priority six months after torrential rains turned the Indus River and its tributaries into destructive torrents. Floodwaters raged from July through September, causing nearly 1 billion dollars in damage to dams and irrigation systems and 93 million dollars damage to water and sewerage facilities, according to relief agencies. The U.N.’s humanitarian affairs agency says only 59 percent of the 1.9 billion dollars in immediate recovery aid has so far been provided.

Lack of safe drinking water, stagnant pools and wrecked or non-existent wastewater disposal are creating a health threat that is magnifying flood recovery problems.

The Red Cross and the South African anti-poverty group ActionAid have both warned that waterlogged and silted croplands are threatening subsistence farming and creating food shortages, and that malnourishment - particularly among children and mothers - is growing.

The Red Cross reported on Jan. 21 that four million people lack adequate shelter, and contaminated water supplies in southern Pakistan are "creating breeding grounds for waterborne diseases."

The U.S. State Department said that more than a million children are at risk of contracting infectious diseases, including waterborne ailments that were a main cause of death among children before the 2010 inundations.

Aside from urgent recovery needs, donors and analysts say Pakistan must address its future water management practices if it is to serve its rapidly growing population of 170 million.

A flood damage report prepared by the Asian Development Bank (ADB) and World Bank says the country’s water supply and sanitation services "fail on three accounts - quality, access, and sustainability of services."

"Piped water supply is frequently intermittent and not potable; only 35 percent of the population has access, at best for 3-6 hours a day in all but the largest cities. Sewerage services are inadequate with most households not connected to a system; 33 percent of rural inhabitants have no toilet," says the 188-page report issued in December.

Still a humanitarian need in Pakistan six months after floods

Most of the people displaced from the Pakistan floods six months ago have returned to their villages. One area in south Pakistan called the Sindh province still has many people in camps still waiting for the flood to recede. Six months later, only half of those people have received any sort of sturdy shelter.

From Reuters AlertNet, writer Megan Rowling describes the continued humanitarian need in Pakistan.

Donors have contributed just over 56 percent of the $1.96 billion requested by the Pakistani government, the United Nations and other aid groups for their relief and early recovery operations, due to continue until October. Breaking that down, only 39 percent of the $322 million needed for emergency and interim shelter has been provided.

Emergency shelter in the form of a tent or two plastic tarpaulins has been distributed to some 864,400 households, according to the International Organization for Migration (IOM). But that means roughly half the 1.75 million families whose homes were destroyed or damaged by the floods have yet to receive assistance to put even a flimsy roof over their heads.

"Shelter remains a concern area, and we have not been able to provide it to 100 percent of people," said Brigadier Sajid Naeem, who heads up the operations unit of the government's National Disaster Management Authority (NDMA). "There is a huge shortage of funding from donors. All the facilities that were destroyed have to be rebuilt on a permanent basis ... but we still need money for transitional and temporary shelters."

The monsoon floods - which happened over several weeks starting late last July, moving from the north to the south of the country mainly along the Indus River - inundated more than one-fifth of Pakistan's territory, killed nearly 2,000 people, and affected some 18 million to 20 million, of whom 14 million required immediate humanitarian aid.
...

Overall, around 95 percent of the 10 million people who were displaced by the flooding at its worst point have gone back to their villages, according to the government.

But aid workers say the humanitarian situation remains particularly difficult in the south, in Sindh and eastern Balochistan, where around 150,000 people are still living in camps because the flood waters have yet to evaporate. On top of that, some 200,000 people are living more or less out in the open near their uninhabitable homes, according to Manuel Bessler, head of the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) in Pakistan.

"They are living in makeshift camps and we are trying to support them by building latrines and getting food to them," he told AlertNet. "This is quite concerning for us because they are scattered and difficult to assist."

Gates and Gulf Prince grant money for child vaccines

$100 million dollars has been pledged from two of the world's richest men to provide vaccines. Children in Pakistan and Afghanistan will receive vaccines with the grant money supplied by Bill Gates and the Crown Prince of Abu Dhabi. The money pledged will buy and distribute vaccines for polio, pneumonia, and other childhood diseases.

From Reuters, writer Reed Stevenson has more on the announcement.

The Bill & Melinda Gates Foundation and Sheikh Mohammed bin Zayed al-Nahayan will each give $50 million to provide vaccinations for five common but deadly childhood diseases, as well as pneumonia, to 5 million children in Afghanistan.

A third of the funds will be used to get the polio vaccine to as many as 35 million children in Afghanistan and Pakistan.

"It's a milestone," Gates, the billionaire co-founder of Microsoft Corp, said in an interview. "We haven't had a joint thing like this in the region."

Gates said the initiative would take advantage of the United Arab Emirates' familiarity with delivering aid to two countries hit by violence and natural disasters. One in four Afghan children dies before their fifth birthday.

"There is no reason why the challenges facing the people of Afghanistan should be compounded by the devastating impact of preventable diseases, and particularly those affecting children," Sheikh Mohammed said in an emailed statement.

Guest Voices: Promoting Grassroots Recovery in Pakistan

Next up in our series of posts from Concern Worldwide is a story on the continued need in Pakistan. Even though the flooding in Pakistan took place over the summer, there is still a great need for recovery. Concern's Press Officer Joop Koopman visited Pakistan to describe a program that gets the citizens involved in the recovery.

Seen from the air, the greenness and neat outlines of the farm fields of Punjab stand in sharp contrast with Sindh Province, its much poorer and more desert-like neighbor to the south.

My colleague Susan Finucane and I are flying from Karachi on Pakistan’s southern coast into the Punjabi city of Multan, an historically significant garrison town in the heart of the country that is today a well-kept, clean-swept bustling city. The relative privilege of the place and the orderliness of local traffic are a far cry from the chaos of urban streets we have just left behind in Sindh.

The ordered lushness observed from altitude makes sense. Punjab is literally the ‘land of five rivers’, fertile, relatively affluent and crucial to Pakistan as a grower of wheat and other crops. A kind of cognitive dissonance takes hold.

Though it is not immediately evident from above, we know that the devastating floods of summer 2010 destroyed more than 1.7 million acres of crops. Punjab is still fertile but the planting and harvest cycle has been violently interrupted, and though the flood waters have mostly receded, the ravages of the disaster will be manifest in drastically reduced crop yields, and the threats of food shortage and disease.

Hundreds of villages were severely affected, leaving up to 6 million people in need of various forms of assistance. The picture gets clearer during a drive into the countryside, where many destroyed fields are in evidence. Far and wide the crops—cotton, wheat, corn—lay abandoned, grey and wilted.

We’re travelling through the largely rural district of Muzaffargah, whose entire population of more than 2.6 million people had to be evacuated in the wake of the flooding. It took the majority up to eight weeks or more to be able to return to their villages, finding most of their homes destroyed, their property washed away, their livestock killed.

A limited effort by the government as well as emergency response initiatives by international aid organizations relied on roadside distributions, which left families vulnerable to attacks and fraudulent behavior by what locals refer to as “professional” beneficiaries. Predatory practices also included the purchase of surviving livestock at cut rates, taking advantage of families’ urgent need to raise emergency cash.

For its part, Concern, banking on relationships with local NGOs, built up and formalized in the past five years or more, was able to distribute emergency supplies in the villages, in the heart of the communities themselves. “Our local partners are our ambassadors in the villages,” said Nauman Shahzad, a Concern program officer based in Multan.

Working through these partner organizations, whose leadership often has family ties in the very villages they serve, Concern also insists on the engagement of the communities themselves in determining the eligibility of beneficiaries. As a result, communities take ownership of the aid efforts, keeping an eye on the most vulnerable families in their midst.

Such is the case for the hamlet of Abas Khan, which is part of the 150 household village of Basti Daryai, where, after distributing emergency shelter materials in the early going, Concern is currently overseeing a comprehensive water, sanitation and hygiene (WASH) program. Administered by the Doaba Foundation, the program is part of a comprehensive approach that aims to safeguard health in the immediate term, while phasing in longer term recovery programs that will address damage done to infrastructure and crops.

Susan and I were honored guests at a community meeting, at which several local leaders gave a low-tech but very thorough and impressive overview of the program —hand-drawn charts and all.

The WASH program consists of latrines connected to septic tanks, hand-wash stations and hand-pumps replacing older pumps, some of which could not tap water deep enough to bypass polluted levels, while others were stolen after the 30-family hamlet’s initial evacuation. Strategically-placed brightly illustrated posters instruct locals about the benefits of hygiene, while a community-based WASH committee organizes regular refresher courses in the improvised village square.

The program has dramatically changed the lives of the local families, even as, naturally, their priorities are the reconstruction of their homes and the resumption of agriculture. “Before we had given little thought to hygiene in the home and in our environment,” says Imam Bakish (50), who is in charge of an extended household of 14, including his wife Pathanimai and nine children. “Our lives are much changed today,” he says; “we keep our bodies and our clothes clean and children are less frequently ill and adults are doing better as well.”In years past diseases caused by unsafe water prompted costly and burdensome journeys to obtain health care.

“There has been such a great change,” says Naseem, a 30-year-old mother of six; “we have gone to more than four [hygiene] sessions and are learning so much.” The program “has helped us a lot and made the village very happy,” she smiled.

Naseem and Imam, whose farming tools were destroyed by the floods that also made his customary plots inaccessible, long to return to work the land—Imam as a farmer and Naseem picking cotton. Only then will their families have a shot at building a new home.

For now, their prospects are good. The land now being reclaimed from the water will actually be more fertile than before. The flood waters deposited another layer of soil richly endowed with minerals that had been carried along as the flooding made its way down along the north-south axis of the country. Concern and its local partners are accordingly shifting focus and massive resources to livelihoods recovery and reviving agriculture across the district.

Guest Voices: Poorest in Pakistan Journey Toward Recovery

For the next installment in our series of posts from Concern Worldwide, we havethis look at recovery efforts in Pakistan. Press Officer Joop Koopman takes a look at the destruction the Pakistan floods caused and how a sanitation program from Concern helps to improve lives.

By Joop Koopman, Press Officer, Concern Worldwide US

We are getting into the thick of our mission to report on Concern Worldwide’s emergency response to the Pakistan’s devastating floods. Susan Finucane, Program Officer, and I have flown to Karachi, provincial capital of Sindh, and have made our way by car to Thatta, the ancient center of Muslim learning, and more rural parts of Thatta district, where Concern is working in close partnership with local organizations.

This is our first look at the destruction left in the water’s wake. Thousands of villages in Sindh have been damaged, and the UN Office for the Coordination of Humanitarian Affairs (OCHA) estimates there are still up to 1 million homeless. Surveying the landscape, the statistics make sense. Highly vulnerable mud houses, characteristic of the extremely poor province, were literally washed away in heavy flooding. Meanwhile, stagnant water in large areas of the province increases the chance of waterborne diseases, a risk factor that will get worse once warmer temperatures return in the spring.

It is jarring to see sudden ‘lakes’ appear in the arid landscape, with half submerged telephone poles making it evident that these are still flooded areas. Roadside shrines and other simple structures clearly bear high-water marks—up to five feet and more. Workers are building new brick ramparts everywhere, as hoped-for protection against future flooding. Tent camps dot the higher grounds.

Our first stop is in the village of Mongo Jakhro, a small community of just 30 households less than a mile and-a-half from the Indus River. Most of the families fled without being able to take along any of their possessions and they returned here only in late October, after spending two months or more at a spontaneous settlement outside of Thatta. Working with a local partner, Concern came to the village shortly after the families’ return to distribute tarpaulins along with bamboo and rope frames. These crude but carefully constructed shelters are their homes for now.

“It is not easy living this way,” said Zeenat Khaskaili, who is 36 and a mother of five. “We are grateful for this shelter, which is much better than having to sleep in the open,” she adds. Her semi-collapsed mud home stands just behind the two tents the family was allotted.

Life is decidedly rough, as most family members have to sleep on the bare floor, their few possessions scattered about. The children are dirty and have nothing to do. A local school was washed away in the floods. There are no latrines as yet. Water and hygiene programs are the next step after the provision of shelter in the emergency effort. “We need a reliable supply of drinking water, mattresses and bedding, as well as kitchen utensils,” says Zeenat, adding that “a latrine is a priority.” A WASH (Water & Sanitation and Hygiene) program will be next for the village.

WASH programs can make an enormous difference in the lives of communities. The village of Aboro Jakhro is a case in point. This medium-sized village is home to 198 households. At the height of the flooding the community was submerged in five feet of water and residents had been forced to spend 50 days in a spontaneous settlement in the nearby town of Makli. But with the villagers’ eventual return came a transformation.

“We have learned how important it is to cut our nails, to wash our hair and wash our hands in order to stay healthy. We are wearing slippers now!” These were the excited exclamations of a group of animated women and girls gathered for one of the village hygiene refresher sessions. Compared to the dirt-strewn and chaotic environment of the previous village, Aboro Jakhro greets visitors with a positively bright, organized and clean-swept appearance.

“Before we never really thought much about hygiene,” says Nooran Merbahar, a 32-year-old mother of five, but “today we wash our hands before and after eating and after we visit the latrine.” Hygienic discipline is paying dividends: “…our children’s diseases have gone away,” says Nooran.

Concern has constructed 44 latrines—plumbing-included, a rarity in rural Sindh—across the village grounds, their temporary frames covered by bright-blue canvas. There are also three brand new hand pumps at strategic locations, each serving a cluster of homes. The old pumps had been destroyed or proved incapable of drawing up water from deep enough to avoid the flood-polluted ground waters.

Here, too, villagers are eager for a return to normalcy and especially an end to living in tents, but Concern’s WASH program is an important first step forward. Accountability is key—each program site is punctuated at regular intervals by posters listing numbers that villagers can call with questions or complaints. Local WASH committees—one for women, one for men—are being trained to keep things going even after Concern has pulled out. The process marks a transformation of the community’s way of life prior to the floods.

Ghulam Mustafa heartily agrees. This 46 year-old father of six heads the men’s WASH committee in the spontaneous settlement of Ed Gah. The camp is the temporary home of 128 families; it is perched on a hill overlooking a river and the almost completely submerged remains of their village beside it: “Many of the diseases we were struggling with have largely disappeared,” he says with a smile that demonstrates a leader’s pride.

“We had to follow women’s lead in paying more attention to what happens in our home,” he says, stressing that the well-being of the young is a top priority. “The “children are our future,” he insists, echoing the message conveyed at hygiene sessions—and to protect them from waterborne illnesses adults have to “keep our kitchens and clothes clean, cut our finger nails and our hair, and wash our hands all the time.”

The road to recovery for the very poorest people in Sindh will be a very long one. But their journey has begun in earnest.

Domestic child laborers at risk of abuse in Pakistan

From IRIN, a story about the mistreatment and abuse of Pakistan's child labor force.

In recent months stories in the Pakistani media of horrendous abuse suffered by some children engaged in domestic work have focused attention on their plight.

In Karachi, the capital of the southern province of Sindh, this month, 14-year-old Muhammad Zafar was rescued by police after neighbours reported the boy had been kept shackled at the home of his employers. He had also not been paid wages for some 19 months.

“His employers told us he had stolen gold items, and we could not see him or take him away till these had been paid for,” Zafar’s mother, Parveen Bibi, told IRIN.
She said the boy had been sent out to work as the family was very poor.

At a busy fast-food outlet in Karachi, several small girls watch over children they are paid to “mind”. Their charges are in many cases barely a few years younger than themselves. In houses across cities, it is common to see children sweeping floors, washing dishes or performing other kinds of work.

They are a part of the child labour force, which consists, according to official figures, of three million children under 18. Of these, according to a 2003 survey in six major cities by the government’s Commission for Child Welfare and Development, 8 percent are engaged as domestic workers.

The International Labour Organization (ILO) puts the number of children working in the domestic sector at 264,000, according to a 2004 report.

“Under-reported”

“The abuse of children who work as domestic labourers is under-reported. These children are often trafficked from rural areas of Sindh and the Punjab, and brought to cities to work. As such they have no one to watch over them and are vulnerable to violence,” Salam Dharejo, national manager at the Child Labour for the Society for the Protection of the Rights of the Child NGO, told IRIN.

He said this year they had documented six cases of death among child domestic workers as a result of violence inflicted on them.

It is believed that rising inflation is forcing families to send their children out to work. “Hardship for almost all families is increasing because food is more expensive,” Sikander Lodhi, an economic analyst, told IRIN.

According to the Consumer Price Index of the Federal Bureau of Statistics, annual inflation was running at 15.37 percent in November 2010. Food price inflation is a key factor in this trend.

“Poverty is a huge factor in people sending children out to work, or selling them to those who use them as labour. The recent floods have also brought an increase in child labour, as people who came into cities after being displaced from poverty-stricken districts in Sindh and the southern Punjab saw opportunities to obtain employment for children in urban households,” Dharejo said.

“My ten-year-old daughter now works in a big house, looking after a two-year-old and doing some cleaning chores. I worry about her constantly,” Saadia Bibi, 40, told IRIN.

Torture, sexual abuse

She has good reason to worry. Last month, in the southern Punjab city of Multan, a child the same age working as a maid was brutally tortured because her employers believed she was possessed by evil spirits.

There have been other allegations of torture involving child maids although in the high profile case of 12-year-old Shahzia Masih, whose employer was accused of her murder in January this year, a court in November acquitted him of the charges.

Mistreatment of child domestic workers, according to the limited research available, is widespread.

Sexual abuse is not uncommon either. According to the Alliance Against Sexual Harassment (AASHA), comprising a group of organizations working against the harassment of women in the workplace, 91 percent of female domestic workers say they have suffered sexual abuse.

Guest Voices: Local Partners are Key to Recovery in Pakistan

Next up in our continuing series of guest posts from Concern Worldwide, is this look at recovery efforts in Pakistan. Press Officer Joop Koopman says that relationships with other NGOs and community members have helped to look to speed recovery efforts from the summer flooding.

Susan Finucane, program officer at Concern Worldwide US, and I have come to Pakistan to report on the progress of Concern’s large-scale emergency program in response to the megadisaster caused by summer’s unprecedented heavy rains and massive flooding that left an area the size of Italy underwater.

Upon our arrival, Dorothy Blane, Concern Worldwide Country Director in Pakistan, briefs us on Concern’s immediate priorities and our approach to this particular disaster, which is informed by a long track record in both long-term development and emergencies in Pakistan.

LONG-TERM RELATIONSHIPS SECURE VITAL REACH

What gives Concern vital reach and flexibility, says Dorothy, is our network of local partners and our long-term relationships with community members in the poorest parts of Pakistan. Dorothy tells us that working with local organizations is “a powerful way to build up civil society.” Concern offers capacity building and technical expertise that benefits and strengthens local NGOs so that work can be sustained in the long term without Concern. The local NGOs Concern partners with in Pakistan closely involve the communities they serve through Community-Based Organizations, an approach strongly encouraged by Concern in its programs throughout the world.

The purpose of Susan’s and my field visit is to see firsthand the impact of the disaster on communities in Pakistan and document the ongoing humanitarian needs, as well as to document the emergency response programs that Concern is overseeing in Sindh and Punjab provinces. Compared to KPK, where the recovery and reconstruction process has begun in earnest, people in Sindh and Punjab still face enormous needs and challenges.

In Sindh, only 30 percent of people displaced by the flooding have been able to return to their homes, with significant parts of the province still underwater, and silted soil has ruined the first post-flood harvest. Many of those who have returned to their villages are still living in makeshift dwellings pending the construction of more permanent dwellings. In Punjab, where most of the water has receded, the big challenge is to make the destroyed crop lands productive again. In KPK, in the north, the advent of winter and cold weather are making the construction of solid housing an urgent matter.

For example, Concern gave 900 farming families from the village of Basti Noon Wada, in District Muzaffargah in South Punjab, 50kg bags of wheat and basic farming tools just before wheat planting season ended in early December. The orderly distribution process managed to serve 500 people a day.

SAFEGUARDING COMMUNITIES AGAINST DISEASE

In the spontaneous settlement of Sonda Eid Gab, in District Thatta in Sindh, 128 families are living in tents and make-shift shelters just up a hillside from where their community once stood at the river’s edge. The remains of a wall are among the few reminders of the existence of a once thriving village, the majority of whose men made their living fishing. Concern built latrines in this settlement to reduce health threats from poor sanitation, and has also been providing clean drinking water to meet the population’s daily needs, along with hygiene education programs. All of these are safeguarding an extremely vulnerable community against waterborne diseases and other health risks.

For the nearly 200 families in the village of Abora Jakhro, a few hours’ drive from the camp, Concern is also building new latrines—complete with permanent plumbing—and the new hand pumps are the pride of the community. “Before we simply never thought about hygiene,” said Nooran Merbahar, a mother of five children. “We were plagued by mosquitoes, and we had to rely on dirty water. All of us got sick.” Those days are now behind her.

Nearly 20 million people have been affected by this disaster, with 7 million in urgent need of shelter, food, water, seeds and tools, livelihood opportunities and repairs to infrastructure such as roads, bridges and, especially, permanent housing.

Through its commitment to local partners, Concern empowers local groups that would otherwise not have the capacity to jump into action or be eligible for significant funding. And once projects get underway, Concern’s monitoring mechanism also ensures ongoing support and training for such local organizations.

BUILDING PAKISTAN BACK BETTER THROUGH LOCAL PARTNERSHIPS

“It often makes no sense for us or other international NGOs to set up and staff local offices when so many committed and capable civil society organizations are already in place,” Blane insists. Local and community organizations have a wisdom and experience that INGOs need in order to ensure local sensitivity, appropriate solutions, and sustainability.

In fact, though Concern began working in Paksitan in 2001, the history of INGOs in Pakistan is a relatively short one, explains Mubashir Ahmed, Concern’s Assistant Country Director. It wasn’t until the 2005 earthquake that INGOs built up a significant and lasting presence in Pakistan, as the crisis highlighted Pakistan’s widespread poverty.

Similarly, the long-term needs of Sindh and Punjab—both suffering from extreme poverty—were not really on the radar until the devastating floods. There was momentum after the 2005 Pakistan earthquake to help build the affected areas back better. That call to action applies even more powerfully today, as Concern is helping lay the groundwork for long-term recovery for millions whose assets and homes were literally washed away by the floodwaters.

US Aid suspends contractor operating education services in Afghanistan

USAID has suspended a contractor from receiving any new government contracts. The contractor is the Washington DC based non profit Academy for Educational Development. A. E. D. is being investigated by USAID for evidence of collusion that inflated the price of goods the non-profit bought. USAID contracted with A. E. D. to provide educational services in Afghanistan and Pakistan.

From the Washington Post, writer Dana Hedgpeth and Josh Boak tell us more about the investigation.

USAID's Office of Inspector General is investigating the Academy for Educational Development (AED), which is based in the District. The 49-year-old nonprofit group contracts with U.S. government agencies and others to run health, education, social and economic development programs in about 150 countries.

AED is also one of USAID's key contractors in Afghanistan, overseeing the government agency's higher-education program in the war-torn country. In the past three years, it has received $109 million in contracts from USAID for work in Afghanistan.

Initial findings by the inspector general's office "reveal evidence of serious corporate misconduct, mismanagement, and a lack of internal controls, and raise serious concerns of corporate integrity," according to a statement from USAID.

AED has 65 contract awards from USAID worth roughly $640 million, according to a USAID official.

The agency said it plans to conduct "an immediate internal review" of "every program associated with AED."
...

USAID recently ended a five-year, $150 million cooperative agreement with AED after its inspector general found evidence of fraud related to a program in Pakistan that was designed to provide disaster relief, infrastructure development, education and agricultural services, according to a recent report to Congress that did not identify the company by name. A source close to the investigation confirmed that the company in the report was AED.

In that Pakistan program, the inspector general's investigation found "evidence of collusion between vendors and staff . . . resulting in overpayment for certain goods," according to the agency's report.

Still one million displaced in Pakistan from flooding

Even though the flooding in Pakistan took place some time ago, there are still over a million people displaced from it. There is a large area in southern Pakistan where the waters have still not receded, so people who used to live in this area still can not return. In the meantime, there are over a million people who still need food, shelter and water from the international community while they wait.

From Reuters, writer Nita Bhalla talks to the U.N. about the latest conditions in Pakistan.

“We have a protracted humanitarian crisis in the south where we still have one million people displaced because of flooding in the province of Sindh,” Manuel Bessler, head of the U.N. Office for the Coordination of Humanitarian Affairs (OCHA) in Pakistan, told AlertNet in an interview.

“The basic survival items of food, water and sanitation, shelter and healthcare are urgently required."

The floods, sparked by unusually heavy monsoon rains, caused Pakistan's mighty Indus river to burst its banks, inundating one-fifth of the country and forcing millions to flee.

Hundreds of thousands of acres of crops have been destroyed and infrastructure such as roads, schools and bridges have been damaged in the provinces of Khyber Pakhtunkhwa and Baluchistan in the north, and Punjab and Sindh in the south.
...

The United Nations says it needs $1.9 billion to provide displaced populations with basic relief items as well as help those returning to repair their homes and generate some income.

But Bessler said donors have only contributed about 49 percent of the funds required and more is urgently needed -- especially for shelter and health services for the 500,000 people who are living in makeshift settlements.

Black market for kidneys has slowed in Pakistan

From IRIN, a story on how new laws have changed the black market for kidneys in Pakistan.

Rehmat Masih, 35, who lives in the predominantly Christian Youhanabad suburb of Lahore, capital of the eastern province of Punjab, is facing hard times.

On a monthly income of around Rs 6,000 (US$70) which he earns by selling sweet drinks from a stall, he can barely provide food for his family of six. To make matters worse, his wife is sick with hepatitis and, to help meet the costs, his two oldest children, Saleem aged 13 and Sumera 11, are forced to work as garbage collectors. High food price inflation has added to their difficulties. Consumer prices rose by 15.71 percent in September, according to official figures.

A few years ago Rehmat would have known just what to do: He would have sold a kidney to gain at least temporary respite from poverty. But though he has approached two middlemen who arrange for hospitals to sell kidneys to wealthy clients requiring transplants, he has not yet received any guarantee he will be able to find a buyer.

Things had been quite significantly different until three years ago. Pakistan had gained a reputation as an international marketplace for kidneys, with around 4,000 kidney transplants taking place annually and only around 25 percent of the organs coming from related donors.

Around half of those receiving kidneys came in from other countries to receive an organ they had bought, usually from impoverished people in Punjab.

“Around 2,000 transplants took place each year, with about 1,500 of these involving foreign buyers who travelled to Pakistan to buy a kidney,” Maj-Gen (retd) Abdul Qadir Usmani, administrator of the National Human Organ Transplantation Authority (NHOTA), told IRIN.

2007 law

Much of this changed with the passage of the Transplantation of Human Organs and Tissues law in 2007. The legislation, under which NHOTA was set up, lays down rules that all hospitals and doctors are bound to follow, bars the purchase of kidneys, and restricts donations - essentially to blood relatives.

Action by police, courts and tough monitoring has helped enormously, as has the awareness raising campaign spearheaded by the Karachi-based Sindh Institute for Urology and Transplantation (SIUT), which actively campaigned for years to have the law passed.

Farhat Moazam, chairperson of the centre for biomedical ethics at SIUT, told IRIN there had been a “decline in kidney sales following the law, though the practice has not ended entirely”. She also said the media had played an important part in driving home the message about the ethical and medical issues posed by the exploitative practice of kidney purchases.

Many of those who have sold kidneys in the past have ended up receiving little aftercare. Some suffered a decline in health or serious psychological issues.

Such people can be found everywhere in Youhanabad - till 2007 a favourite recruiting ground for those engaged in the kidney trade. “I have been suffering pain in my side, blood in the urine and other issues since the operation to remove my kidney in 2006. I was also not paid the full amount of Rs 300,000 [$3,529] that I was promised,” Pervaiz Ahmed told IRIN.

“Today we are afraid to approach people openly to obtain a kidney and those who wish to do so are sworn to strict secrecy,” said a middleman who asked not to be named. He said “most hospitals” which had previously bought kidneys had stopped doing so, especially after the high-profile arrest of six people, including five doctors in 2007, for involvement in selling kidneys.

Such measures have also led to people re-thinking about selling organs. “My uncle sold a kidney, but I would never do so because it is wrong for a rich man to buy a part of my body. Besides police can arrest anyone who sells an organ,” said Nadeem Ahmed, 25, a bicycle repairer.

Maj-Gen Usmani said the law had been “very successful” and since 2007 there have “been allegations but no proven cases of violations”.

Courts have also played their part in acting to stop the practice. In June 2009 the Supreme Court of Pakistan sought details of kidney transplants carried out at two hospitals, after a complaint that illegal transplants continued. Both hospitals gave an undertaking that illegal transplants were not being carried out.

But despite such measures, violations are occasionally reported. In October this year an Omani national died in Lahore after receiving a kidney that had been bought from an unknown donor.

“When surgeries take place in backdoor clinics there is a much greater risk of complications for both the recipient and the vendor,” Moazam said. She also told IRIN that only an increase in the donation of organs by those who had died would reduce the demand for kidneys, which fuels illegal purchases. The law lays down procedures for such donations, but these are extremely rare due to social taboos and a lack of awareness.

Rehmat Masih is aware of the new law and says he would “rather not” sell an organ, but says for now he has no choice, because he has no other way to meet his family’s pressing needs.

Video: submerged Pakistan three months later

Three months after the floods began, many areas of Pakistan are still under water. This video from OXFAM shows how the need still exists even though funds to help are drying up.

Video: a child's struggle against the Pakistan floods

From this Save the Children video that we found at the Guardian, this story profiles a child who is struggling to help her family survive the Pakistan floods.

Malaria from the flood-waters begins to spread in Pakistan

Large areas of Pakistan remain flooded two months after the disaster began. These large pools of water have become a breeding ground for mosquitoes and malaria is beginning to spread to people who live nearby. The World Health Organization says that there are already 250,000 suspected cases of malaria, while Plan International warns that over 2 million people could soon become infected.

From this Guardian story, writer Declan Walsh gives us the latest update from Pakistan.

Aid agency Plan International worries the figure will surpass 2m. "The most vulnerable are women and children," said its Pakistan director, Haider Yaqub.

The malaria threat is part of a wider health emergency, with more than 20 million people affected by the floods struggling to cope as the winter approaches.

Last night the UN reported 881,000 cases of diarrhoea, 840,000 cases of skin diseases and almost 1m cases of respiratory disorders. Dr Dana van Alphen of the WHO said: "There are no epidemics yet – it's not Goma in 1994. But we have to be very careful."

Increasing UK aid to £134m recently, the international development secretary, Andrew Mitchell, warned of extremely serious public health dangers.

The floods have devastated Pakistan's flimsy public health system. More than 500 clinics have been damaged, while the government estimates that 30,000 "lady health workers" – a programme that is the backbone of the community health system – have been made homeless.

Pregnant woman are a particular concern. An estimated 50,000 flood-affected woman will give birth in the coming month, 7,500 of whom will require surgery for pregnancy-related complications.