The World Will Never Know: An Anthropological View of Humanitarian Aid in Response to the Pakistan Floods

| October 19, 2012 | 0 Comments

Senan Ebrahim (Quincy ’12, Neurobiology) was President of the Undergraduate Council in 2011. He is currently working for Harvard for Pakistan to support flood-relief efforts in Pakistan, building support for the Fair Harvard Fund, and running the Boston Marathon to raise funds for PBHA’s Summer Urban Program.

Image credit: U.S. Department of State.

In August 2010, the worst floods in recent history struck Pakistan, precipitating a humanitarian crisis and widespread destruction of health infrastructure and loss of access to clean water. Floods resurged in 2011, leading to a prolonged disaster with thousands of immediate fatalities and twenty million people displaced, most of them impoverished villagers (Kronstadt, 2011). The consequences for the health of the internally displaced person (IDP) are considerable given the three main epidemics facing the displaced population: cholera, malaria, and dengue fever. The humanitarian challenge presented by this unholy trinity of flood-precipitated diseases is both immediate and severe. However, despite the scale of the disaster, the international aid response has been limited. This analysis considers the possible underlying causes of the limited humanitarian response and its implications for future humanitarian efforts, with a focus on how knowledge-flows could effectively improve the aid response.

To recapitulate the current public health challenges in Pakistan, malaria, dengue fever, and cholera all present as acute medical problems, although they are epidemiologically chronic (Ahmed, Nanji, & Ahmed, 2011). The worst epidemics in Pakistani history occurred in the post-monsoon months of 2010 and 2011, with an estimated 500,000 people suffering from cholera, 100,000 from malaria, and 50,000 from dengue fever (Ahmed et al., 2011; Akhtar, Dutt, & Wadhwa, 2010). Like the Haiti cholera outbreak after the earthquake, the ongoing Pakistani epidemics are acute-on-chronic events ( Farmer, 2011). A consortium of NGOs working in Pakistan reported that there remain nearly one million victims of the 2010 and 2011 monsoons living in makeshift accommodations with no access to aid, with hundreds of thousands of them vulnerable to an impending “public health crisis” (Pakistan Humanitarian Forum, 2011). An October 2011 report by the UN Office for the Coordination of Humanitarian Affairs (OCHA) documents the use of medical services by over 500,000 people, most of whom were suffering from some kind diarrheal disease, as well as the deaths of dozens of children and infants in “suspected malaria” cases (OCHA, 2011). The scale of these epidemics is already alarmingly large with the trend continuing to move in the wrong direction, despite the best intentions of organizations providing medical aid (Pakistan Humanitarian Forum, 2011).

Malaria, cholera, and dengue fever are all debilitating infectious diseases that cause great pain and sometimes death; young children are at high risk for all three diseases (Parliament Committee, 2011). Though the etiologies of mosquito-borne malaria and dengue fever differ from those of waterborne diseases like cholera, their epidemics in Pakistan can all trace back directly to the flooding. The persistence of stagnant water left behind from the floods encourages mosquito breeding, while the admixture of untreated sewage and drinking water via floodwater allows Vibrio cholera pathogenic bacteria to flourish (Akhtar et al., 2010). Khan et al. report the first evidence of evolution of insecticide-resistant dengue mosquitoes in Pakistan, further complicating the biology of combating malaria through pesticide sprays (Khan, Akram, Shehzad, & Shaalan, 2011).

The social disruption and migration patterns of IDPs have exacerbated the health crisis in Pakistan. As was seen in the global health crises of Uganda and Haiti, IDPs often congregate in camps, many of which are now administered jointly by the military and relief NGOs. Dr. Muhammad Nizamuddin, a sociologist and demographer with 24 years of experience at the UN, reports that other IDPs have set up shantytowns in urban areas while they await requisite the requisite financial and material aid to resettle their villages and rebuild their homes (2011). The flooding destroyed $500M worth of crops that were the sole source of livelihood for approximately eighty percent of the affected farmers, many of whom still idle unemployed in the camps, now reliant entirely on aid (Kronstadt, 2011; Parliament Committee, 2011). Poor administration of aid and lack of prioritization of restoring agricultural self-sufficiency means that “opportunities to help hundreds of thousands of farmers plant their winter crops in November [2011] have been missed” (Pakistan Humanitarian Forum, 2011). It is estimated that at least $100M will be spent on foodstuffs in 2012 as a one-time expenditure that could otherwise have been invested in agricultural restoration or medical care (Nizamuddin, 2011). Still other IDPs have not reached camps or major urban areas and have instead dispersed throughout the Sindh, Punjab and Pukhtunkhwa provinces, making aid administration even more challenging given the destruction of transportation infrastructure (Stephenson, 2010).

International aid organizations prepared a response in the immediate aftermath of the Pakistan floods as they had done for other disasters in the past decade, but this disaster’s response was dramatically less successful. UN OCHA fundraising benchmarks were missed throughout 2010 as funds stalled at around 40% of the $1.6B total goal; by contrast, national governments exceeded all OCHA benchmarks for Haiti after the earthquake, donating over $12B, supplemented by $1.3B from NGOs (Fisher, 2010; OCHA, 2011). The level of aid contributed by national governments is subject to a variety of identifiable foreign policy objectives and budgetary considerations, but the contributions of individuals to NGOs are governed by more nebulous criteria. The discrepancy in aid from common Americans in particular is most surprising when identical methods were used: for instance, the Red Cross ran a text-to-donate drive for Haiti which generated over $30M in revenue in just a few days while the same drive launched eight months later for Pakistan generated only $10,000 (Fisher, 2010).

Considering the scale of the disaster, the discrepancies in funding are even more staggering. The Haiti earthquake, Indonesian tsunami and Kashmir earthquake each raised hundreds or thousands of dollars per victim globally ($1087, $1249, and $388 respectively), whereas worldwide donations totaled a mere $16 per victim for the Pakistan floods (Fisher, 2010). Fundraising for Pakistan in 2011 continued to flounder, with donor governments providing limited funding even in response to the UN’s “Rapid Response” Appeal (OCHA, 2011). After it became apparent within a few weeks that government donations for the humanitarian mission would once again be limited, NGOs struggled to contribute funds from strained discretionary budgets owing to lackluster grassroots fundraising campaigns of their own, according to a senior fundraising officer at a prominent NGO. Most notably, the funding levels are lowest in terms of percentage of need met for the categories of water/sanitation/hygiene (20%) and health (36%).

Edwards and Hulme note the propensity of NGOs to work in compartmentalized domains in terms of both services and geography and thereby constitute a schizophrenic whole provider of services. Their assessment of this tendency is validated in Pakistan where the unreliable “patchwork quilt” of social services they cited has become a reality, according to humanitarian workers (Edwards & Hulme, 1996). Edwards and Hulme also note a successful innovative service provision project in Pakistan from the 1990s called the Orangi Pilot Project that installed new sanitation systems at one-third the cost for a conventional system from the government or private sector. According to Nizamuddin, now Vice-Chancellor of the University of Gujrat, non-profits aspire to meet the bar set by Orangi, planning methodical innovation; however, lacking careful central management, the NGOs and GROs (grassroots organizations) collectively create a system of unreliable and uneven services.

The failure of NGOs to address the vast crisis in Pakistan truly calls into question their abilities as the cornerstone of global humanitarian aid operations. Edwards and Hulme advocate uncontroversially for increased attention to the accountability and performance ability of NGOs (1996). However, the limited nature of this change belies the need for a more drastic improvement to the global modus operandi for disaster management. Zaidi posits that the solution lies within the state, urging a drastic reform of state welfare programs (1999). However, reliance on the state would be regressive because of the inherent inefficiency of bureaucratization and the irreparably poor reputation of Pakistani government services. An alternative proposal for how to improve the relief operations within the NGO framework will be fielded following consideration of an essential question: why was the humanitarian response so limited?

The 2005 Kashmir earthquake provides an interesting counterpoint to the 2010-2011 Pakistan floods because around the same time, an earthquake centered in the same region received far heavier global media coverage and far larger donations. One key difference is that monsoon floods, unlike earthquakes and other instantaneously devastating natural disasters, are not telegenic events since they naturally excite fewer emotions of awe and empathy in all people (Fisher, 2010). In a study that surveyed non-profit executives and Atlanta residents of various socioeconomic backgrounds (as potential donors to humanitarian causes), Van Slyke and Brooks demonstrated that while charitable behavior has positive bivariate correlations with many personal attributes (volunteerism, Christianity, etc.), nearly every demographic group can be most effectively targeted via market segmentation (2005).

In the case of the Pakistan floods, a particular kind of impedence of knowledge-flow prevented transmission from the NGO to the busy American consumer: lack of an effective marketing strategy (Feierman et al., 2010). Kleinman’s pioneering idea of knowledge-flow as both a process and a goal is highly relevant to the global humanitarian effort responding to the Pakistan floods. Kleinman and colleagues describe empowering social action at all levels of engagement in the health sector, creating a broad coalition with common cause to overcome barriers to the multidirectional exchange of information (Feierman et al., 2010). Given modern communications technology, this approach could be effectively applied to relief operations, with the networked coalition extending from patients to workers to donors to executives.

Multimodal knowledge-flow also should be better incorporated into the health programs operated by aid organizations in Pakistan. Given the many needs of victims, health concerns can often be overlooked in relatively uncoordinated aid relief efforts. In addition to being underfunded, health programs are generally not prioritized for development and deployment in the aftermath of floods because the need is considered secondary to food security, and the logistical difficulty of implementing health programs is considerably higher. Decision-makers at OCHA and the governments that fund them are simply too distant from the local actors in Pakistan; top-down management structures further impede the “upward flow” of local information (Feierman et al., 2010; K. A. Stewart, Keusch, & Kleinman, 2010). On the victims’side as well, there is a lack of attentiveness to their own medical needs, which is one of the most critical barriers to knowledge-flow.

Aid workers in Pakistan face further challenges that can be readily addressed using the approach of increasing knowledge-flow. For instance, in contrast to the trauma portfolio system that was an unintended consequence of humanitarian action in Haiti, Nizamuddin describes a culture of stoicism where suffering in silence is the norm. If aid is offered, it is graciously accepted, but actively seeking aid of any kind for oneself has pejorative cultural implications, particularly in Punjab and Pukhtunkhwa (2011). Farmer aptly addresses this type of cultural limitation on one’s agency as an instance of universal structural violence, especially when occurring among impoverished people with no conceptualization of healthcare as a human right (2003). A community-based medical program a la BRAC that engages local women by freeing up the most local avenues of peer-to-peer knowledge-flow could be very successful in overcoming this barrier to aid delivery.

Enterprising university students in Pakistan have established schools to teach refugee children in overflowing urban centers (Nizamuddin, 2011). In the global health field, the concentration of flood victims in Pakistan can similarly be capitalized on in joint medical, economic and educational programs as well. For instance, all the healthy former farmers in the camps can be given work opportunities in innovating and producing preventative local products to assist with stemming the disease epidemics – products like sari filters for drinking water (to prevent cholera and other waterborne illnesses) and netting to keep out mosquitoes (responsible for dengue fever and malaria).

Unlike the successful local response, the international NGOs ultimately failed to rally the world to the Pakistani cause because of a drastic breakdown in local to global knowledge-flow. Nizamuddin retrospectively suggests that Pakistani academics such as himself should have engaged more critically with the humanitarian crisis and leveraged global academic networks to convey the realities of the situation laterally, as well as provide direct insight on the ground in Pakistan. Reflecting on his work in natural disasters and complex emergencies in other developing nations, he notes the unique “dearth of demographers, ethnographers, and sociologists documenting the unfolding crisis in Pakistan” (Nizamuddin, 2011). The breakdown in knowledge-flow thereby begins at the flood basin itself. NGOs would do well to partner with experienced Pakistani anthropologists, given that most volunteers on the ground are relatively young and inexperienced Pakistani students.

Most large NGOs have a predominantly top-down knowledge-flow in management, with limited reciprocity – unlike the ideal multidirectional model of knowledge-flow proposed by Kleinmman and colleagues for global health programs (Feierman et al., 2010). A further impediment to knowledge-flow is the fact that donors are generally concentrated in the global centers, while aid recipients are predominantly in the global periphery. Bridging this gap is a perennial challenge in global health (Stewart et al., 2010). The knowledge-flow discussed by Kleinman and colleagues can be manifested in several forms, as discussed, but one of the most important ones for the future of the Pakistan flood relief program is an aggressive public relations campaign soliciting the American donors who gave generously to Haiti.

Nizamuddin’s parting comment that “the world will never know” of the suffering in Pakistan epitomizes the centrality of knowledge-flow to the anthropological understanding of humanitarian aid and suggests the need for a ‘knowledge economy’ rather than a ‘moral economy’ among humanitarian aid organizations. Humanitarian actors who are maximally informed on local to global levels will be best prepared to respond effectively to future global health crises. Perhaps Nizamuddin’s comment is best read as a challenge to humanitarians – an invocation to act, lest “the world will never know.”


  • Ahmed, B., Nanji, K., & Ahmed, K. (2011). SP3-19 Preparedness for malaria prevention in relief camps for flood affectees: a cross sectional survey from Pakistan. Journal of Epidemiology & Community Health, 65(Suppl 1), A413-A414. doi:10.1136/jech.2011.142976o.19
  • Akhtar, R., Dutt, A. K., & Wadhwa, V. (2010). Malaria in South Asia: Eradication and Resurgence During the Second Half of the Twentieth Century. Springer.
  • Edwards, M., & Hulme, D. (1996). Beyond the magic bullet: NGO performance and accountability in the post-cold war world. Kumarian Press.
  • Farmer, Paul. (2003). Pathologies of Power: Health, Human Rights, and the New War on the Poor (1st ed.). University of California Press.
  • Farmer, Paul. (2011). Haiti After the Earthquake. PublicAffairs.
  • Feierman, S., Kleinman, A., Stewart, K., Farmer, P., & Das, V. (2010). Anthropology, knowledge-flows and global health. Global Public Health, 5(2), 122-128. doi:10.1080/17441690903401338
  • Fisher, M. (2010, August 23). 4 Reasons Why Americans Aren’t Giving for Pakistan Flood Relief. The Atlantic. Retrieved December 9, 2011, from
  • Khan, H. A. A., Akram, W., Shehzad, K., & Shaalan, E. A. (2011). First report of field evolved resistance to agrochemicals in dengue mosquito, Aedes albopictus (Diptera: Culicidae), from Pakistan. Parasites & Vectors, 4, 146. doi:10.1186/1756-3305-4-146
  • Kronstadt, K. A. (2011). Flooding in Pakistan: Overview and Issues for Congress. DIANE Publishing.
  • Lautze, S., Leaning, J., Raven-Roberts, A., Kent, R., & Mazurana, D. (2004). Assistance, protection, and governance networks in complex emergencies. Lancet, 364(9451), 2134-2141. doi:10.1016/S0140-6736(04)17555-7
  • Nizamuddin, M. (2011, December 1). On Pakistan Flood Relief Efforts: An On-The-Ground Perspective.
  • OCHA, U. O. for the C. of H. A. (2011). Pakistan Monsoon 2011 ( No. 7). Situation Report. United Nations. Retrieved from
  • Pakistan Humanitarian Forum. (2011). 100 Days On: Pakistan’s Flood Survivors Need a Surge of Support. Pakistan Humanitarian Forum.
  • Parliament Committee, Great Britain Parliament H. of C. I. D. (2011). The Humanitarian Response to the Pakistan Floods: Report, Together with Formal Minutes, Oral and Written Evidence. The Stationery Office.
  • Polman, L. (2010). The Crisis Caravan: What’s Wrong with Humanitarian Aid? Macmillan.
  • Rai, M. A. (2011). Epidemic: Control of dengue fever in Pakistan. Nature, 479(7371), 41. doi:10.1038/479041d
  • Scherer, R. (2010, August 18). Why many Pakistani-Americans aren’t sending flood donations home. Christian Science Monitor. Retrieved from
  • Stephenson, J. (2010). Health Risks in Pakistan. JAMA: The Journal of the American Medical Association, 304(15), 1659. doi:10.1001/jama.2010.1450
  • Stewart, K. A., Keusch, G. T., & Kleinman, A. (2010). Values and moral experience in global health: bridging the local and the global. Global Public Health, 5(2), 115-121. doi:10.1080/17441690903484201
  • Van Slyke, D. M., & Brooks, A. C. (2005). Why do People Give? The American Review of Public Administration, 35(3), 199 -222. doi:10.1177/0275074005275308
  • Zaidi, S. A. (1999). NGO failure and the need to bring back the state. Journal of International Development, Journal of International Development, 11(2), 259-271.

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