“It was just the perfect storm for malaria” – Pakistan responds to surge in cases following the 2022 floods

The recent floods were a massive setback for Pakistan’s fight against malaria and a warning for the world of how climate change will impact disease response efforts.

Last summer, Pakistan experienced the worst flooding in its history. At its height, more than a third of the country was underwater and 33 million people were affected. Within a few weeks, the estimated cost of damages exceeded US$ 15 billion, with over one million homes destroyed, 2 million acres of crops flooded, and 500 000 kilometres of roads damaged.

And that was only the start of this flood’s terrible toll. Even before the waters receded, the mosquitoes came en masse, driving the worst malaria outbreak in the country since 1973.

“The flood totally upended anti-malaria efforts in Pakistan,” says Dr Allan Schapira, a WHO consultant who recently conducted a review of Pakistan’s national malaria programme. “It largely hit the districts that had the most difficult malaria situation already, and it had the biggest impacts on the poorest people – those who normally live hand to mouth, in subsistence agriculture, or very small shops, and so on. Crops got destroyed, people lost their jobs and the little cash they had.”

When the rains started to subside, there were huge collections of stagnant water everywhere, noted Dr Schapira. “It was just the perfect storm for malaria.”

Progress in curbing malaria before the floods

Pakistan had been making steady progress against the disease. In the more populous parts of the country, such as Punjab province, industrialization and socioeconomic development led to stronger health systems while better water management and rice cultivation practices helped mitigate the stagnant pools where malaria-carrying mosquitoes often breed. As these areas approached elimination, the focus turned to more rural and remote regions, such as the Khyber Pakhtunkhwa and Balochistan provinces, which border Iran and Afghanistan, as well as the province of Sindh.

“Before the flood, there was gradual progress in malaria control,” notes Dr Samira Al-Eryani, a WHO technical officer who witnessed the devastating impact of the flooding in Pakistan first-hand. Key antimalarial activities included distributing insecticide-treated nets for vulnerable populations and increasing the availability of rapid diagnostic tests and treatment. “If the flood hadn’t happened, they could have continued to bring down the malaria numbers given these important ongoing interventions,” she added.

“Pakistan is a very diverse country, and there are many areas that are difficult to reach,” says Izaskun Gaviria, senior fund portfolio manager with the Global Fund, which has supported anti-malaria efforts there since 2003. “Nevertheless, the malaria situation was becoming better and better, to the point where some of the provinces were close to elimination. Then the flood hit, and it turned the situation upside down.”

Reaching the “unreachable”

In fact, Pakistan saw at least a four-fold increase in the reported number of malaria cases after the floods, from 400 000 cases nationwide in 2021 to more than 1.6 million cases in 2022 in the 60 districts supported by the Global Fund (meaning there were very likely many more). Two provinces in particular – Balochistan and Sindh – saw an exponential increase in cases in a short period of time.

Worryingly, an increasing number of these cases were caused by the P. falciparum malaria parasite, which can become fatal quickly without treatment. And after the flood, many communities were unreachable. “It was extremely challenging to reach people during the floods. Roads were destroyed, and people were scattered everywhere,” says Dr Al-Eryani.

“Because the water was so high, there were many millions of people that were fairly inaccessible for several weeks,” notes Dr Gaviria of the Global Fund. The families and villages isolated by the insurmountable waters did not have any access to water, electricity, medicine or information, even as malaria tore through their communities. “Many of the young people we spoke to reported they had never been so sick in their lives. It was hard, very hard.”

Even those who escaped the floods had to contend with the swarms of mosquitoes now breeding in stagnant pools of water. “I remember visiting areas where people had been displaced from their homes and villages and had nowhere to stay,” recalls Dr Mah Talat, Executive Director of the non-profit Indus Hospital & Health Network, a group of healthcare facilities across Pakistan that provide services for all patients free of charge. “It was getting dark, and you could see the mosquitoes everywhere, like large clouds of fleas. I remember thinking, how are these people going to stay here at night, in this dark, haunted place without any facilities?”

Compounding matters even further, the flood didn’t just accelerate a malaria outbreak. Many other diseases and health problems also rode in the flood’s wake, from diarrhoea and cholera to hunger and even snakebites. “The flood brought many health problems,” notes Dr Talat. “There’s no clean drinking water, so we saw more diarrhoea. People are living on the roadside without protection or anything to eat. They’re extremely vulnerable and are being bitten by mosquitoes. So all kinds of vector-borne diseases and infectious diseases thrive.”

“Unexpected and unprecedented”

Nobody was prepared for such a massive deluge. “The 2022 floods were unexpected and unprecedented,” says Dr Qutbuddin Kakar, a WHO official in Pakistan. “There was no signal that we would have this level of floods and heavy rains. Some malaria-endemic districts in Balochistan had been experiencing a dry spell for four years.” But suddenly, rainfall was 6 to 7 times above average in these districts, even for the monsoon season.

In short, “the main culprit behind these floods,” says Dr Talat, “is climate change.” In northern Pakistan, warmer temperatures melted glaciers and caused rivers to surge while, south of the country, sustained heating of the Indian Ocean led to extraordinary levels of rain.

While Pakistan contributes less than 1% of the world’s greenhouse gas emissions, it is already bearing the brunt of climate change’s impacts. “Unfortunately, we are the victim of climatic changes for which we are not responsible,” says Dr Baseer Achakzai, Director General of Pakistan’s Health Ministry. “There’s no justice in it in terms of who created this problem and who’s now impacted.”

The response, and the road ahead

© WHO/Panos Pictures/Saiyna Bashir. Umaida Hatoon receives antimalarial medicine for her 6-month-old son after he tested positive for malaria at a mobile health clinic supported by WHO in Balochistan, Pakistan (March 2023).

As soon as the flood hit, international health organizations such as WHO and the Global Fund came together with local governments and NGOs to combat the malaria outbreak in Pakistan and help address the extraordinary scale of need. The response drew on both the oldest and newest interventions in the anti-malaria tool kit. In the makeshift refugee camps, nets were distributed, tents (and what houses remained) were sprayed with insecticides, and mass drug administration campaigns were conducted to quickly treat as many people as possible.

In addition, responders took advantage of innovations such as foldable bed nets (which are better suited to small tents), mobile health clinics that provide malaria diagnostic and treatment services, and portable solar panels to produce light, electricity, and mobile phone access for information updates.

Thanks to these efforts, the immediate malaria crisis seems to be receding. “We can see that mortality, and especially infant mortality, is back under control,” says Dr Achakzai. “We have also been able to provide to our district health systems the basic equipment and test kits for malaria, HIV, and tuberculosis.” In addition, Pakistan will focus on building out the health and human resource infrastructure to reach more people living in remote areas of the country.

Dr Achakzai cautions, however, that “there is a lot to do,” and funding remains an issue. “We cannot rely 100% on [international] funding; there should be domestic resources as well.” WHO’s Dr Kakar agrees. “Many provinces are under-resourced and focused on other competing priorities. [Malaria] was not considered a big threat, but with this flood calamity, the threat is now real.”

Nor has the threat diminished just yet. Malaria cases usually decline in winter, and the disease could return with a vengeance in the monsoon season to come. “The situation is still tricky,” warns Dr Talat. “People have gone back to their homes, but many health facilities are not functional or still underwater and, due to the warm season, malaria is again coming back.” Unless national and provincial government officials, donors, and responders all stay vigilant, she adds, there will be a “huge surge in cases” in the year to come.

Reaching those most vulnerable to malaria will require the engagement of all members of society. “We must involve each and every person in society in anti-malaria efforts,” says Dr Achakzai, “including community leaders, opinion makers, politicians, and of course parliamentarians and policymakers. [All must do more] to better reach those who do not have access to health facilities.”

© WHO/Panos Pictures/Saiyna Bashir. A group of men trained by WHO embark on an indoor residual spraying (IRS) campaign in Sohbatpur, Balochistan. IRS is a WHO-recommended intervention to prevent malaria. 

If left unchecked, the potential surge could become a regional crisis. “Because of border trade with Iran and Afghanistan, the resurgence of malaria in Pakistan is a major threat for the malaria control and elimination initiatives [in those countries], as well as for elimination efforts in Saudi Arabia,” said Dr Kakar. A surge in malaria cases could also pose a threat for countries within and outside the region that are already malaria-free.

Dr Al-Eryani concurs. “We need to be more prepared and invest more in preparedness. We were not ready for this level of major outbreak. We need to ensure that malaria interventions are timely, effective, and available when and wherever they’re needed.”

For now, Dr Schapira is “cautiously optimistic” about the road ahead. “If we get the [necessary] support for all the districts, then I think the situation in 2024 will be almost back to normal. And, from 2025 onwards, we will be back to a bit less malaria every year. Pakistan could actually get back on track for achieving malaria elimination around 2035, which is their official goal,” he added.

This may not have been a normal transmission season – but with climate change, it could quickly become the new normal, both in Pakistan and in many other places.