ultali is one of the most stunning geographies in the world. It is home to the Royal Bengal tiger and more than four million people who have been at the forefront of the climate change battle.

As the water level rises and frequent cyclones destroy lives and livelihoods, people in this riverine delta are facing a battery of health problems - skin ailments, waterborne diseases and gynaecological problems.

As the sea level rises, they are forced to abandon their homes and move to high ground every few years. In recent years, frequent cyclones have wrought havoc, forcing many to move to other states, leading the lives of unacknowledged climate refugees as they take up work at construction sites in places like Delhi and Kerala.

Since 2007, devastating floods have also become a way of life in faraway Khyber Pakhtunkhwa, once known as the North West Frontier Province of Pakistan. As recently as the first week of March this year it saw 30 casualties. Aftershocks of the catastrophe are felt long after the water recedes - in the form of malaria, water borne disease, skin diseases and atypical pneumonia and influenza cases. Diseases that were not known earlier have arrived here. The KP recently reported its first case of monkey pox.

130,000 cases of influenza were reported in this region bordering Afghanistan and crisscrossed by rivers. The province, like the rest of the country, is also facing the brunt of respiratory illnesses linked to the rising air pollution levels. World Health Organization estimates that air pollution is responsible for more than 130,000 deaths a year in Pakistan. In 2023, a diarrhoea outbreak swept through three KP districts - Dir Upper, Dir Lower and Karak - after the floods.

More than 300,000 cases were reported. Cholera is now endemic in Pakistan. The WHO considers a single laboratory-confirmed case as an epidemic threshold. Peshawar, the capital of KP, is one of the epicentres of the post-flood cholera outbreaks.

Fighting tigers, crocodiles and climate change, Jayanta Mondol, 64, has been a farmer in the Kultali block of the Sunderbans all his life. Never before has he been forced to rebuild his life from scratch as often as he has had to since 2019 when the area saw four successive cyclones - creatively named Bulbul, Fani, Amphan and Yas. The last one the area saw before that was when Aila hit in 2009. But that is not the only thing he is concerned about.

Kultali is one of the 19 blocks in the Sunderbans designated as belonging to a fragile biosphere. “Earlier, even in summers, we could work in our fields until 12 noon. But now it has become so hot that it is impossible to work beyond 9 am. People are getting sunstrokes. We had never heard of those earlier,” he says.

The rainfall pattern has changed. The yield has declined because the fertile season is now shorter. It is past mid-March, and there is still such thick fog. All the buds on the mango tree have been destroyed. We already know that our hopes of a good mango crop are futile,” he says. The changes in cropping patterns, say experts working in this area, have aggravated the malnutrition problem. The conversation about climate change in the Sundarbans tends to gravitate towards its impact on the health of the mangrove vegetation and the future of the tiger population rather than the impact on the health of this massive population living on the frontier of climate change.

The rising sea level and the increasing salinity of the water are pushing human habitation further inland. Those choosing to stay back face the brunt not just of the obvious suspects like malaria and dengue fever but also of commonplace ailments that have suddenly become more frequent and more virulent. “On the one hand, in these areas, we see rising incidence of waterborne diseases: diarrhea and gastroenteritis, etc. On the other hand, with crop failures becoming more common, there is rising malnutrition.”

Kultali has a high number of tiger widows - women whose husbands have been killed by tigers. The women also become victims of crocodiles because of the practice of catching crabs in the water in the tiger reserve. This practice also makes them vulnerable to skin infections, menstrual irregularities and miscarriages. The children of malnourished parents and those of migrants who almost never take their children with them struggle with mental health problems.

The public healthcare system fails to reach these people. More importantly, there is a lack of credible data that can help us quantify the problem,” says Dr Sugato Hazra, a former director of the School of Oceanography in Jadavpur University. His team is currently working on a project to look at the impact of climate change on the health of people in the Sunderbans.

Dr Amitabha Chowdhury, who has worked in the Sunderbans for the last 25 years, says contrary to perceptions, malaria is not on the rise in the area.

“Dengue fever is rising but often that is because of migrants returning home and carrying the disease from their places of work. The easier communication has come with advantages, but it has also meant both people and diseases are travelling more freely,” says Dr Chowdhury.

The devastation of the cyclones leaves scars among adults and children alike. There is considerable medical literature analysing the suicidal tendencies among inhabitants of the Sunderbans. According to a 2013 article in the journal ISRN Psychiatry that dealt with a participatory approach to prevent suicides by pesticide consumption: “The ecological character of this region is largely responsible for its remoteness, backwardness (human development index—0.55 in contrast to 0.62 for the district), and varieties of psychosocial community stresses (natural calamities like storm, cyclone, inundation of saline water into the agricultural field, crop failure, poverty, domestic violence related with dowry demand, alcoholism and gender discrimination, etc.)” The absence of a public health system - for Kultali, the nearest qualified medical doctor is about an hour away in Jamtala - is being filled in, albeit inadequately, by the non-government sector.

Baikunthapur Tarun Sangha is one such organization. It used to run a maternity hospital in the area. As funds dried up, the hospital was forced to shut down shop, but the BTS continued to organise village health camps. “We see a lot of women with menstrual irregularities come to these camps. Many complain of white discharge. Skin ailments are pervasive, as are digestive and gastrointestinal problems. The salinity level of even pond water in some areas is high. Four back-to-back cyclones have broken the economic backbone of the area, causing much more migration than earlier. Children get left behind. When we go to the field, these are the children that we will see not mingling, sitting in a corner. Adolescents become vulnerable to trafficking because there is nobody at home to take care of them,” says Sushanta Giri, the BTS director. For people, the changing weather conditions and the rising incidence of some diseases are disparate conversations that they will enthusiastically participate in. But the linkage between skin and eye allergies, the common medical advice (dispensed by quacks) of avoiding pond water (because of its high salinity) in many diseases, the menstrual irregularities, miscarriages and white discharge to the unseasonal fog and intense heat is not yet established.

There is a dearth, even in academic journals, of work that cohesively and conclusively links climate change and health. In Kishori Mohanpur village, Tumpa Sau’s fisherman husband just left for a construction job in Thrissur in Kerala, leaving her and her young child at home. She says: “We are constantly battling digestive issues and skin and eye allergies. Eye allergies sometimes take years to heal. For skin infections, the doctors usually say ‘do not bathe in the pond.’ We also have a serious problem of white discharge, which is very common. For that too, doctors ask us to avoid pond water.” The ‘doctor’ in question is almost always a quack. Quacks here do not even deny their lack of medical degree.

There are two classes of doctors, MBBS who rarely ever come to these parts, and when they do, demand a hefty fee; and the quacks that do home visits, daily dressings, etc. Quack Bageswar Das’s clinic is well stocked with medicines, which he sells while dispensing medical advice.

He happily agrees to speaking on camera to talk about his job of ‘helping people.’ “Most of my patients come with scabies, skin infections, diarrhoea and pneumonia. Women have a lot of UTIs that they catch because of the practice of catching fish and crabs while standing in the water. Many people report menstrual irregularities, but it is difficult to link those to climate change,” he says.

The shortage of fresh water has aggravated over the last few years. A water mafia started selling whatever fresh water is available to farmers in dire need. Battling old scourges and new 35-year-old Engineer Khalil Ahmad, suffering from a severe chest infection, is waiting for his checkup at the Lady Reading Hospital in Peshawar. “Due to climate change, many people around me are facing chest infections and other complications. Peshawar has become one of the most polluted cities in Pakistan. We are paying the price,” he says. Sana Ahmed, also seated in the waiting area, says that she has been sick for a week. She says has been diagnosed with influenza. Initially, she had a seasonal ailment but now she has caught an influenza-like virus, says her doctor.

Dr Anila Basit, an associate professor at Lady Reading Hospital and a pulmonology specialist, says: “Because of climate change, diseases like influenza, flu and chronic obstructive pulmonary disease are increasing. Asthma has started affecting rural women because they mostly use biomass coal or wood fires to cook their meals. The frequent floods in Khyber Pakhtunkhwa are also increasing the incidence of many viral diseases,” she says.

A recent United Nations report claims that 44 per cent of children suffer from stunted growth primarily because of malnutrition. This is a consequence of Pakistan’s food insecurity and poverty, which are linked to climate change. Unseasonal rains and smog are contributing to viral, waterborne and vector-borne illnesses like Zika virus, Dengue fever, typhoid and malaria.

According to a WHO report amongst the vector-borne illnesses, malaria could pose a threat to around 46 million people annually by the year 2070, Outdoor air pollution is a huge contributor to respiratory illnesses. Data collected in major cities of Pakistan has shown sa considerably higher value than the mean PM 2.5 levels recommended by the WHO for a clean environment.

Dr Irshad Ali Roghani, public health director at the Directorate General of Health Services, says: “When we analysed our data for 2023 when flood hit many areas of Khyber Pakhtunkhwa, we found that the effect was not just of damaging the economy of the province. Diseases like malaria, skin diseases and other vector-borne diseases were reported in large numbers. KP recorded 130,000 patients with influenza as well. Climate change has led to a spurt in throat infections and upper respiratory infections.”

The KP government has organised special training sessions for district health officers in water-borne and vector-borne diseases. The first case of monkey pox was reported recently. The Health Department plans to create a Resilience Centre to tackle the disease. Pakistan formulated a National Climate Change Policy in 2012. A framework was laid for its implementation in 2014. Pakistan Vision 2025 is a comprehensive plan that includes positive inputs on the future of sustainable development and economic growth in the country.

Dr Shumaila Javaid, a consultant pulmonologist, says, “Climate change is a pressing discussion. Rising temperatures, fluctuating humidity, disturbed air quality, plenty of aeroallergens and mighty dust storms are a significant threat to health, leading to illnesses and fatalities. Children, elderly individuals and those with pre-existing respiratory conditions are especially susceptible to the health effects of climate change.

“At one end of the spectrum are heat waves exacerbating existing cardiovascular diseases and respiratory disorders; on the other, there is an increase in vector-borne diseases like Dengue fever and malaria. The increasing temperatures because of climate change are conducive to the breeding of disease-carrying vectors.” The increasing pollution levels and crop failures because of climate change that trigger nutrition insecurity add an additional dimension to that problem, she says.

“Burning of fossil fuels and the release of greenhouse gases contribute to poor air quality. This has led to respiratory problems from worsening allergies to infections and exacerbations of existing disorders like the COPD and parenchymal diseases, all because of climate change-driven air pollution. This is particularly concerning in densely populated areas like Peshawar city,” she adds.

Abantika Ghosh is a journalist and author. She tweets @abantika77 

Wisal Khan is a freelance journalist based in Peshawar.

This report is part of a cross-border reporting project commissioned by the US-based East-West Center