The monsoon rains have historically brought mixed fortunes to Pakistan. While they help spur the cultivation of crops, changing demographics and population distribution have given rise to recurring catastrophes the rains leave in their wake. As Pakistan suffers from another cycle of floods in both rural and urban areas, recent weeks have seen the explosion of a dengue fever epidemic in central Punjab. In the past two weeks alone, more than 6,000 cases have been reported, with the majority occurring in Lahore. At least 40 deaths  have now also been reported. The extent of the epidemic is such that schools in Punjab have been closed for the last ten days.

Dengue fever is a mosquito-borne viral infection. While most cases present with non-specific symptoms such as fever and muscle aches, in about 1 percent of cases, the disease progresses to a more dangerous condition called "dengue hemorrhagic fever." In this condition, the normal human clotting process becomes deranged, resulting in spontaneous bleeding in patients, leading in some cases to death. In the appropriate context, dengue can be diagnosed without the help of any advanced laboratory tests. However, treatment options are limited only to supportive measures, such as providing anti-fever and pain medication, as well as using transfusions to combat platelet deficiency, though no "cure" or vaccine exists.

Dengue fever epidemics have become a cyclical nightmare in Pakistan over the last several years. The infection was quite rare in South Asia before the turn of the century, but starting in the last decade, dengue epidemics have become a regular occurrence, usually peaking in September and October. As the population in Pakistan grows or people move around in search of economic opportunity or safety from militant violence, settling in many places into overcrowded urban slums on the outskirts of cities like Lahore.

These slums are hotbeds of contamination, given that the proliferation of these ramshackle neighborhoods outpaces that of adequate infrastructure development. With hygienic practices already poor, they grow worse in such settings, where public sanitation is often subpar. The best measure to prevent dengue can be by halting the reproduction of mosquitoes or preventing mosquito bites. Mosquitoes reproduce in stagnant water, and unless widespread measures are taken to drain such collections or fumigate mosquito-prone areas, the insects continue to proliferate, helping spread infections.

The current armed conflict in Pakistan has also been a key driver of disease. The plains of Punjab provide a home to millions of internally displaced refugees who have moved away from the war-torn northeastern and tribal regions, bringing with them an increase in disease. Furthermore, war itself is known to be one of the most potent fomenters of infectious disease: Studies have shown that "complex emergencies" can cause a several-fold increase in infection rates.

But aside from these direct environmental factors fueling the spread of dengue, another potential cause of the infection's appearance might well be climate change. Like most other infections spread by an intermediary organisms (like mosquitoes), dengue transmission increases with atmospheric temperature and humidity, since higher temperatures and moisture optimize mosquito breeding.

Complicating this problem further is emerging evidence that Pakistan's mosquitoes are developing resistance to insecticide that is used to eliminate them.

Unfortunately, many of the factors contributing to dengue outbreaks, from poor hygiene and sanitation to climate change, are risk factors common to most infectious diseases. If no major changes occur, Pakistanis could be exposed to a host of epidemics, such as measles, pneumonia, and cholera.

One important reform would be to empower public health specialists to develop overarching strategies to reduce factors leading to transmission. However, the medical community in Pakistan is focused on other things, with young doctors in Punjab on strike for long periods of time this year protesting low wages. Given that there is such resentment among trainees, who form the backbone of the clinical work force, it is likely that these protests are also adversely affecting the response to the current epidemic, as there are fewer doctors available to try and stem the crisis.

Since neither cure nor vaccine exists for dengue fever, prevention is the only option to control the human and economic cost of the epidemic. While the local media has criticized the government's response, one has to consider that they are over whelmed by several public health crises spanning the length and breadth of the country simultaneously, such as the widespread floods, ongoing polio transmission and rampant malnutrition. Nevertheless, improving hygiene and sanitation, in addition to helping better-manage public infrastructure development and population growth, remain the only long term solutions for preventing dengue, and other infections, from breaking out.

Haider Warraich, MD, is a research fellow at Harvard Medical School. He is a graduate of the Aga Khan University in Karachi, Pakistan, and the author of the novel, Auras of the Jinn.

This week, Pakistani President Asif Ali Zardari put the fight against polio at the forefront of his domestic agenda, announcing emergency measures to vaccinate 32 million children at risk of the disease. Pakistan is one of four countries in the world to continue to suffer serious incidences of the disease, and this new attention to polio eradication shows how far the world has come in battling the disease, while also showing the serious challenges standing in the way of eliminating it forever.

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The floods in Pakistan in 2010 were massive. The rains affected the length of Pakistan, maximally impacting the provinces of Khyber-Pakhtunkhwa (KPK), Punjab, and Sindh as well as parts of Baluchistan. Flooding displaced more than 20 million people and covered about one fifth of Pakistan's arable lands -- an area roughly equal to the U.S. eastern seaboard. This flood affected more people than the 2005 Kashmir earthquake, Hurricane Katrina (2005), Hurricane Nargis (2005), the Indian Ocean tsunami of 2004, and the 2010 Haiti earthquake combined. Irrigation systems were destroyed, crops ruined, and seed stockpiles devastated. More than six million heads of livestock (including poultry) were killed. Yet, amazingly, only 1,985 people perished while another 2,946 were injured.

Given the population density of the affected regions, the poor infrastructure, and the baseline level of poverty, these figures are astonishingly low. In spite of the physical destruction, the fact that fewer than 2,000 Pakistanis died suggests that the Pakistani government did something very well last summer. Amidst numerous ongoing internal security crisis, political challenges and shortfalls of international assistance, Pakistani agencies continue to manage this crisis well despite the serious challenges that remain.

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Barely hidden beneath the surface of Pakistan's worst flooding in living memory were the geopolitical stakes shaping both the justifications for official Western assistance and how aid was delivered to victims of the disaster. The perverse result may be a further restricting of the ability of humanitarian aid workers to assist the Pakistani population in the most volatile areas of the country.

I have just returned from Pakistan where I visited flood zones and discussed with Médecins Sans Frontières/Doctors Without Borders (MSF) staff the relief effort and its implications for humanitarian aid in the country. While the primary responders to this crisis have been the communities themselves, MSF has 1,200 Pakistani and 135 international staff providing assistance in 15 locations throughout the country.

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The scale of the calamitous floods experienced in Pakistan after the monsoonal rains this year has quite clearly been beyond the capacity of an administratively and financially drained state. But instead of concentrating on the flooding itself, the media and political analysts have instead concentrated on revelations made about Pakistan's apparent double game in Afghanistan and on criticizing the government severely after President Zardari made the politically unwise decision to leave Pakistan after the onset of the flood for a state trip to Europe. The disaster wreaked by the floods has also been analyzed through the lens of terrorism and corruption, rhetoric that is commonly used when talking about Pakistan, taking away the focus from the flood and the vulnerability of Pakistan's population.

This vulnerability is both physical and institutional. Much of the death and destruction that has ensued since the floods began could have been prevented if the institutions responsible for the provision of security (the Pakistani government and the irrigation department in particular) had responded more effectively to the crisis. An uncritical media has reproduced not only stereotypical depiction of hazards and disasters as natural but, in this particular case, has contributed to vulnerability by creating a particular depiction of Pakistan, its people and government. Furthermore, vulnerability of the Pakistani state needs to be examined at yet another level and that is the dependency of the government on foreign aid and its alliance with the United States for its sustenance.

The lack of capacity and expertise of the Pakistani government was made apparent by the mismanagement of the national disaster and the unsatisfactory response to provide relief to the flood-affected areas. There has been a complete lack of initiative taken by the Pakistani government towards natural disaster management and relief, whether after the Kashmir earthquake in 2005, Cyclone Yemyin in 2007, an earthquake in Ziarat district in Baluchistan in 2008, or the current flooding. The ordinance that had led to the creation of the National Disaster Management Authority had lapsed when the floods occurred. Hence, the government was incapable of launching a coordinated relief effort because provincial and district-level counterparts declared that the federal government should not interfere in provincial matters. On top of this, it is important to recall that Pakistan has one of the world's most complex irrigation systems, and the irrigation department's complete ineptitude at managing the flood waters was also the result of years of neglecting the maintenance of irrigational headworks and barrages located on river Indus.

Additionally, Pakistan's problems with democracy and governance were highlighted through the exposure of its ineffective citizen-state relationship, one primarily based on patronage and clientelism. Political parties in Pakistan have only been active in the electoral context; they have served to aggregate potential winners instead of interests, and politicians tend to buy the support of constituencies through direct compensation during elections (such as through patronage jobs and localized rather than national investment). In the context of the flood it rapidly became obvious that legislators elected to be the conduits for the communication of societal interests to the state were unable to perform this function in the non-electoral context. A common complaint heard in most of the flood-affected areas was that the people had no access to their political representatives or government institutions in their time of need.

The government's ineffective response also drew attention to the imbalance in between the civil and military spheres in Pakistan. The military as an institution was better organized and equipped to reach the flood-affected areas to carry out rescue and relief efforts. This not only underscored the inability of the civilian government to provide basic social services to the people in times of crisis, but also impacted the popularity ratings of the present government. This decrease in popularity for the government will in turn make it harder for the civilian government to operate in the future, a dangerous situation in a country with a history of military rule.

Finally and most significantly, the growing threat from Taliban and jihadi insurgent groups became obvious in the flood's aftermath. In the aftermath of the 2005 Kashmir earthquake, President Musharraf had encouraged banned jihadi organizations to help in the relief effort. This time the affected areas were even nearer to home and the population again put into close contact, and even at times dependent on, organizations with loyalty to the Taliban and al Qaeda.

Accompanying these challenges posed by the flooding are Pakistan's inefficient economy, ineffective legislature, weakly-institutionalized party system, corruption at every level of government and deep-set ethnic and religious cleavages that have led to a spike in violence in the past few months.

Moving beyond the immediate context of providing relief to flood-affected areas, the big question looming in everyone's mind is whether the Zardari government will survive the severe criticism it endured in the past few months as a result of its failure to deal with the aforementioned problems.

However, the political problems in Pakistan are so extreme that no opposition political party would rationally consider toppling the government, because it would not want to "clean house" and confront the challenge of state-building and regime survival. It would be more prudent for Pakistan's opposition parties to simply wait till the next election to defeat Zardari's enervated and unpopular Pakistan People's Party. But this further delay in dealing with Pakistan's problems could worsen an already bad situation, making the hope of a smooth transition to power for the next government even more tenuous.

It was bound to create controversy and outrage in a country fixated with Dr. Aafia Siddiqui. The sentencing of the Pakistani neuroscientist -- dubbed the ‘Grey Lady of Bagram,' the ‘daughter of Pakistan' and ‘Prisoner 650' by her supporters -- in a New York court on Thursday has riled many in Pakistan, including the government that had campaigned for her release.

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The severe aftermath of the flooding in Pakistan has called attention to the need for not only humanitarian aid to help the tens of millions of Pakistanis affected by the flooding, but also for long-term sustainable development assistance to help Pakistan rebuild its critical infrastructure. The United States has a long history of giving development aid to Pakistan starting in the 1950s, but the question lies in whether these funds are actually used effectively for development projects.

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Militants in Pakistan have a limited track record of providing aid to refugees in times of crisis. Amid the country's most recent human tragedy, its flood disaster, militant groups or affiliates are allegedly offering social services and relief in affected areas, generating concern that aid will translate into long-term support for these organizations. But while no substantial evidence exists to suggest that militants will seize control in Pakistan, fear inside Washington among experts and policymakers suggest that terrorists' might seize the country's tribal areas-a concern that would turn back the clock on U.S.-Pakistani counter-terrorism efforts.

Pakistani President Asif Zardari's government has increasingly framed the disaster within the context of the Islamist militant threat in Pakistan, pointing the finger at al Qaeda and its affiliates-including legitimate religious charities-for preventing the government to provide adequate assistance to victims of the flood disaster. But according to a former senior U.S. intelligence officer, "blaming al-Qaeda will not mask the corruption, inefficiency, and ineptitude, and nepotism that have characterized the Zardari regime. Unfortunately, it's taken such a tragedy to highlight Zardari's feeble leadership." 

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Fears of targeted killing at the hands of the Taliban operating in and around Peshawar, the capital of Pakistan's recently renamed Khyber-Pakhtunkhwa province, have forced the leadership of Pakistan's key secular parties to stay in hiding instead of going out in public and governing. This absence of leadership has provided an opening for religious and pro-Taliban elements to win the hearts and minds of the hundreds of thousands in the area rendered homeless by the devastating floods ravaging Pakistan.

Hamstrung by their meager resources and lack of capacity to deal with such a huge calamity, the local and central governments have responded to the crisis far slower than the religious charities, which benefit from armies of volunteers and extensive funding. These charities have outdone the government by helping rescue trapped people, as well as providing shelters, cooked food, warm clothes, and emergency health services. They have also used their relief efforts as a propaganda opportunity, displaying banners replete with Islamist slogans and telling flood victims that the disaster occurred because Pakistanis have not obeyed God or implemented sharia.

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Unwelcome news

The U.N. announced yesterday that up to 4 million people have been made homeless as a result of flooding in Pakistan, as increased aid struggles to keep up with demand and Pakistan's top meteorologist said the floodwaters would not fully recede until the end of this month (Reuters, AP, NYT, BBC, ET).

The U.N. will convene a conference today to push governments to give more to Pakistan's relief effort, and the U.N. official in charge of the response to the 2004 tsunami said of the response, "[i]t's been abysmal, it's been terrible. There is no relationship between the number of people in acute need of help and what has actually been provided in this first month" (AP, BBC, Wash Post, Daily Times, NYT). Disease continues to break out among those displaced by flooding, especially children (Reuters, Dawn, ET).

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A very long goodbye

In an interview with Foreign Policy magazine published yesterday, U.S. Defense Secretary Robert Gates suggested that he may step down sometime next year (FP, Guardian, CBS, AP). Gates noted in the interview that a 2011 retirement would give him the chance to oversee the December 2010 Afghan strategy review and the completion of the additional troop deployments ordered by President Barack Obama while avoiding the need for Obama to look for a replacement in an election year (FT, Reuters). Gates also said there was "no question" that a drawdown of U.S. troops would begin in 2011, which appears to run counter to suggestions that ISAF commander Gen. David Petraeus might seek a delay in the scheduled withdrawal (Tel, AP, USA Today).

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Unspeakable

Gunmen in the remote Badakhshan province in northeastern Afghanistan killed 10 members of a medical assistance team at the end of a three-week mission to provide eye care to isolated parts of neighboring Nuristan province (LAT,  AP, VOA, NYT, WSJ). The team worked for the International Assistance Mission (IAM), which has been in operation in Afghanistan since 1966, and was returning from Nuristan when gunmen with "red dyed beards" came across them, took their possessions, and shot ten of them, including six Americans, one German, one Briton, and two Afghans. A Taliban spokesman claimed credit for the attack, saying the group were proselytizers and spies, charges that the group's director in Kabul denied vehemently (CNN).

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