Karachi, Pakistan: Disaster Mitigation in the City of Migrants

Published on June 30, 2014
Earlier this year, a delegation from Harvard's South Asia Institute visited the Aga Khan University Hospital and observed some of Pakistan's unique emergency care challenges.

Large swaths of congested, illegally-built houses in Karachi—known as katchi abadis—have little or no access to public services.

One of the most populous cities in the world, yet one of the least understood, especially in the West, is the bustling port-city of Karachi, home to over 20 million residents and financial capital of Pakistan. Spread over 1360 square miles, Karachi is a dense urban agglomeration accommodating over 15,000 people per square mile. Tracing its roots back to the old town of Kolachi, settled by Sindhi and Baloch tribes, Karachi saw exponential growth in the second half of the 20th century. Starting with a population of about 400,000 on the eve of Pakistan’s Independence in 1947, the city absorbed wave after wave of migrants—first Muhajirs from partitioned India, then immigrants from the newly independent Bangladesh (erstwhile East Pakistan), and finally Pashtuns from Khyber Pankhtunkhwa, the Federally Administered Areas, northern Balochistan, and Afghanistan.

Consequently, Karachi is now a bustling South Asian metropolis, with all the trappings of modern South Asian cities: overcrowding, unplanned growth, inadequate rapid transit facilities, poor water and sanitation facilities, unsafe housing, unorganized labor, and an unflappable, can-do populace with hopes for a better tomorrow.

Burden of violence

In addition to the challenges faced by rapidly expanding urban centers, Karachi faces the constant threat of terrorism. In 2013, there were 94 bombings in Karachi—one every four days. More than 700 Karachiites were injured, and 124 died. As recently as April 24, 2014, six people were killed and over 30 injured as a result of another suicide bomb in the city. The bombings have not spared healthcare facilities, either. In 2010, as victims of a bomb blast were being brought to one of Karachi’s premier public hospitals, Jinnah Post Graduate Medical Centre, a bomb went off outside the emergency department, shattering glass, breaking walls and injuring and killing patients and staff. Dr. Seemin Jamali, who has served as chief of the emergency department at JPMC for two decades recollects the day vividly. “We were busy taking care of the crowded emergency department when there was a huge explosion and I was thrown to the ground. One of my staff helped me out.” The sporadic bombs and targeted killings continue unabated, adding a sheen of perpetual uneasiness to daily city life. This reign of violence overlays all other medical emergencies in Karachi, including an astounding 30,000 annually reported road traffic injuries.

Philanthropy and commitment: the evolution of emergency medicine in Karachi

Victims of accidents and injuries are taken to one of several hospitals in Karachi, including the Jinnah, Civil, Abbasi Shaheed and Aga Khan University hospital, each with varying capacities to respond. While most of these facilities do not have formal EM training programs, all of them mobilize existing resources to respond to this large burden of violence on a daily basis.

Victims of accidents and injuries are taken to one of several hospitals in Karachi.

In 2004, when Dr. Junaid Razzak returned home to Karachi after more than a decade spent in the US and Sweden completing his advanced medical and public health training, there were no emergency medicine specialists in all of Pakistan. Most hospitals had a one- or two-bed “casualty ward,” typical of hospitals across South Asia, that served as receiving rooms for patients coming to the hospital. Most patients arrived by foot, bus, two-wheelers, or taxis. Some had private cars. A few called for an Edhi ambulance. Edhi ambulances, about 400 of them, driven by volunteer drivers and sponsored by the Edhi Foundation, were then the only organized emergency medical service in all of Pakistan. Started by Pakistani philanthropist Abdul Sattar Edhi, the ambulances met a critical need: they ferried those that had no other means of transport. Dr. Razzak, who had dedicated his doctoral thesis to the evolution of Edhi ambulances, knew that this critical, life-saving service was only the first of a series of interventions necessary to provide state of the art emergency medical services to one of the largest cities in the world.

Earlier this year, a delegation of public health practitioners from the Harvard South Asia Institute joined Dr. Razzak’s team on rounds in the emergency department at the Aga Khan University Hospital (AKU) in Karachi. A gleaming 48-bed emergency room, bustling with emergency physicians and nurses hovering over their patients, many of whom were attached to several intravenous lines, monitors, and ventilators, looked like any other in the United States—save the intricately latticed windows that allowed natural light to filter in. “This area is for patients on BiPAP,” explained Dr. Munawar. “We have over-crowding issues. The hospital is often full, and we must take care of the patients while they are waiting for a bed. We have many patients with cardiopulmonary issues, and starting our own BiPAP unit has been very helpful.” Behind Munawar was another familiar sound—residents clicking away at the EMR—final proof that emergency medicine as we know it had arrived in Pakistan. Fondly remembering the decade he served as chair of the department he helped build, Dr. Razzak recalled the time when patients did not understand what to expect in the emergency department. While some were surprised at the plethora of services now available at the hospital’s doorstep, others couldn’t comprehend why they couldn’t just be transferred to a room upstairs. And, it seemed, nobody understood triage.

The AKU emergency department runs the flagship emergency medicine residency training program in Pakistan. To date, the program has graduated 12 residents, most of whom have continued their careers in EM in Pakistan and other countries. The department also boasts a robust research division staffed by several doctoral candidates, epidemiologists and biostatisticians. A Fogarty-funded grant has helped advance research capabilities through collaboration with the Johns Hopkins Bloomberg School of Public Health. The department is also a WHO Collaborating Center on Emergency Medicine and Trauma, and has grant support from the WHO and the NIH. Dr. Razzak noted that the AKU model stands apart from its many counterparts in the region, where the department has not sought foreign collaboration or endorsement. “The faculty have developed their own rigorous standards of education, examination and certification with quality being the primary driver,” said Razzak.

The AKU emergency department runs the flagship EM residency training program in Pakistan. A Fogarty-funded grant has helped advance research through collaboration with the Johns Hopkins. The department is a WHO Collaborating Center on Emergency Medicine and Trauma, and has grant support from the WHO and the NIH.

As we stepped out of the emergency department into the warm afternoon sun, we saw a bright yellow Aman ambulance pull into the ambulance bay. Two uniformed paramedics deftly extricated their patient from the ambulance and trotted up the ramp into the ED. The patient was breathing through an oxygen mask and had an intravenous line. Dr. Razzak smiled. “At Aman, all our paramedics and nurses receive six months of rigorous training. We now have 100 ambulances and have an average response time of 8 minutes for acute cases. Traffic density and road behavior remain our greatest challenges.” Aman Foundation, started by a Dubai-based Pakistani philanthropist, Arif Naqvi, is one of the most recent players in the social sector, but one with a highly visible footprint. Focused on health, education and nutrition, the Foundation espouses the mantra, “transforming lives,” which it seems to have successfully done by providing parts of Karachi a state-of-the-art EMS system in a mere five years. Dr. Razzak also runs the Aman Healthcare Services, a system now comprised of a paramedic training school, EMS, Telehealth services, and community and school health programs.

The constant threat of targeted and random violence has not deterred Karachi’s physicians from committing themselves to advancing medical care. With government support and private donations, Dr. Jamali has also rebuilt her emergency department. A large concrete barrier stands in front of the entrance; the ED can now only be accessed by passing through several security checkpoints. Vehicles, including ambulances, are parked a short distance from the entrance and carriers run stretchers to and fro. As Dr Jamali walked us through the various new additions to the ED, one could not help but notice the constant state of vigilance the providers were under. In her office, two television screens were tuned onto news channels 24/7. “I have to keep looking at these screens. We have to be prepared at all times. You never know when something bad is going to happen again.”

Katchi abadis: Karachi’s informal settlements

In spite of these impressive strides in emergency medicine and preparedness, much still remains to be done. The majority of Karachi’s population have limited or no access to these services, especially those provided by the private sector. To reach the masses in Karachi, it is important to examine the social fabric of Karachi’s society, and the distribution of wealth along its ethnic and geographic divisions.

Just north of Jinnah Hospital is Shahar-e-Faisal, or national highway 5, which begins its journey at the Karachi port and then makes a wide north-south sweep across Pakistan linking the historic cities of Hyderabad, Multan, Lahore (close to the border with India) Gu- jranwala, Rawalpindi, and Peshawar (on the border with Afghanistan). After a brief period of decline when the nation’s capital was moved from Karachi to Islamabad, Karachi regained its stature as the nation’s economic engine. Consequently, upwards of 45,000 migrant workers are now estimated to arrive monthly in Karachi, from as far at Peshawar and Quetta. As is the case with almost all South Asian cities, Karachi has no organized mechanism to absorb this large influx of migrants, and they take refuge in informal shelters in unplanned settlements, mostly across ethnic and regional divisions. This large, unchecked, continuous migration significantly stresses the city’s limited infrastructure, civic amenities, and law and order provision.

Professor Jennifer Leaning from Harvard University accompanies Dr. Razzak at a visit to the Aman Ambulance control room where televisions are tuned onto news channels 24/7.

Karachi has long struggled with the challenge of its Katchi Abadis (“impermanent settlements”), that have continued to grow through Pakistan’s years of military rule and elected governments. The Katchi Abadis have either lived under the threat of regulation (implementation of existing zonal laws, eviction and prevention of further settlements), or have successfully managed to mobilize the political process toward regularization (post hoc legalization of existing settlements). This phenomenon is ubiquitous in Asia, Africa and Latin America. Regularization most often happens in incremental milestones—all of which are necessarily intertwined in local politics: the issuance of identity cards with addresses, gas and electricity connections, water pipes, etc. This is important from the standpoint of disaster management because “formalization” often ends with the provision of these basic utilities. The private sector attempts to step into the void to provide other equally important services like healthcare, education, and employment. Mr. Ahsan Jameel, CEO of Aman Foundation, contends that there is only so much the private sector can do. He expects Aman to provide an evidence-based robust model of sustainable service delivery, but sees partnership with the public sector a necessary ingredient of scalability.

Dr. Razzak, Mr. Jameel, and their team at Aman are now committed to strengthening Karachi’s disaster management system, with special emphasis on medical response and mental health. Dr. Sadia Qureshi, who also returned to Karachi after several decades of practice in the UK, heads Aman’s mental health program. “We must figure out how to build resilience in these communities,” notes Dr. Quereshi as the team recognizes the multiple onslaught of isolation, poverty, illiteracy, social marginalization and the constant threat of eviction and violence faced by the urban poor.

Remembering Virchow: mapping Karachi’s vulnerabilities

Disaster management plans in South Asia, including those of the National Disaster Management Authorities in India and Pakistan, are sound in principle. However, they fail to achieve their desired goal for lack of administrative will to address implementation gaps. Most government plans focus on rescue and response and pay lip service to mitigation. The scope of government aid does not extend to the tens of millions that live in informal settlements across the cities of South Asia. For these millions living at the brink of poverty, the impact of a disaster-event can be so detrimental as to push them into a downward spiral of extreme destitution. The lack of social and economic safety nets among the urban migrant poor makes them significantly more vulnerable than their better-off neighbors.

In spite of Karachi's impressive strides in emergency medicine and preparedness, much still remains to be done.

Effective mitigation and response strategies require a deep understanding of the social, economic and cultural milieu of these cities, a point reiterated often at the Pakistan Urban Forum during the South Asian Cities 2014 Conference in January. At this gathering, domestic and international scholars acknowledged the complex, evolving identities of today’s South Asian cities. Disaster preparation in Karachi must therefore now expand far beyond the confines of “response” to include robust mitigation strategies built around community resilience: social, cultural and economic. In addition to violence and urban accidents, Karachi is also prone to monsoon floods, and is a short distance from several existing and proposed nuclear plants. The impact that most of these events would have on the various populations of Karachi would vary tremendously. Mapping the risks and vulnerabilities of Karachi’s socio-economically diverse populations would be a prerequisite to meaningful disaster planning for the city. Mitigation strategies will require a whole range of solutions that may include highly polemical political interventions like regulation and regularization, or the less controversial expansion of EMS services, or social programs like micro-insurance schemes to build resilience among the urban poor. As local Karachi institutions begin partnering with international universities and hospitals, it is imperative that all stakeholders, whether foreign or domestic, adopt this comprehensive approach early on.

“Disaster planning” collaborations in the region are often limited to highly visible mock-drills and medical training. In spite of the enthusiasm and eagerness of all participants, much of what is taught and learnt at these drills is hard to integrate into existing systems for want of political will required to facilitate the necessary personnel and resource allocation. There is growing recognition among stakeholders across the region that in addition to capacity building, a concomitant drumbeat of advocacy and policy making is essential.

In the mid-nineteenth century, Virchow noted, “Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution... The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” Today, Dr. Razzak, Dr. Qureshi, Mr. Jamal, and their team are committed to understanding and addressing the social determinants of disease in their community. Those of us that will partner with them are equally obligated to delve deep into Karachi’s socio-economic milieu to formulate meaningful strategies to make the city safer and healthier for its citizens.

This article originally appeared in Issue 13 of Emergency Physicians International.

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