The Jati Baloch communities settled on public ‘waste’ (JB2a) land between 1960 and 2000, moving inland as a result of sea intrusion and coastal erosion. Ongoing environmental degradation continues to threaten their current locations, while heavy monsoon rains and cyclones regularly cause floods and an increase in mosquitoes. A cyclone in 1999 was particularly destructive, when over 3,700 villages and 1158 km2 of agricultural crops were destroyed [
11]. Floods up to four feet high killed two people and half of all livestock in one respondents’ community. Others recollected losing homes and possessions as the dam breached, saving their children on their fishing boats. Their camels were left to fend for themselves, as “camels are safe, they can swim” (JB3a). These Kharai, or ‘swimming camels’, are slowly becoming extinct due to the destruction of their ecosystem [
40]. While the loss of animals may reduce the presence of zoonotic pathogens, this also reduces the availability of food and nutrition, impacting people’s health and in turn their immunity against zoonotic pathogens from other sources, including as a result of environmental changes.
The Kalmati Baloch communities move annually during the monsoon in the late summer months, while slow-onset disasters such as drought and salination further impact their livelihoods. Households move independently over 18 – 25 km, and may choose different destination locations than other community-, or even family members, depending on the availability of food and water for themselves and their livestock, as available forage does not suit all animals. While this may improve nutrition and animal health, in these areas animal and human populations interact with those from other villages, which may increase their vulnerability to zoonotic pathogens they were not earlier exposed to.
There are distinct tribal and cultural differences between the Kalmati and Jati Baloch communities, as well as within families and households, reflected in livelihoods and displacement context, gendered roles and livestock keeping, which influences which specific zoonoses people are vulnerable to. Furthermore, men and women experience displacement differently, as women are more involved in preparation and restoration, while also responsible for taking care of sick household members and animals, increasing their risk of zoonotic disease.
Below findings are presented based on the main themes constructed from the thematic analysis, drawing on the differences and similarities between respondents to support recommendations for further research and policy.
When the water comes
Both abundance and shortage of water is linked to ill health and disease in the literature. Water-borne zoonoses are common in flood related disasters [
41,
42]. Respondents only moved once water physically entered their lives, destroying homes and agricultural land, however, disease itself is an important secondary driver for displacement. Animal and human disease determined respondents’ displacement dynamic, moving to avoid disease, or becoming restricted by disease outbreaks.
Among the Kalmati, each year animals are lost through injuries, the increase in vectors, or through infectious diseases in flooded areas or at the destination location, as floods exacerbate the burden of insects, pests and pathogens in the Delta’s warm and humid environment [
16]. One man and his animals died during the 2019 monsoon as a result of a traffic accident, while snake bites are common.
"Two of our calves died [a week] after coming here, I have no idea what disease they got, they [were] drenched in water, the place was flooded with rain water when we left (…) My cousin lost his cow and [another] cousin lost two or three sheep." (KB1a, Kalmati Baloch male livestock herder, Jungshai).
Dead animals are buried, as respondents know from experience the risk of infectious disease spread. The Jati Baloch and their camels experienced fever and cough in the aftermath of the 1999 floods, while camels suffered infertility due to malnutrition following the disaster. Exhaustion and a lack of nutrition as a result of the disaster or displacement are other causes for livestock loss, affecting households’ food security.
Respondents’ livestock is regularly affected by the non-zoonotic, but highly contagious Foot and Mouth Disease (FMD), locally known as ‘Samarro’, identified through its clinical signs, primarily a loss of milk production, fever, drooling and lesions around the mouth and on the feet, and the loss of young animals [
43]. Respondents noted that their animals are particularly vulnerable to the disease in the dry hilly areas, where they graze close to herds from other households and villages.
"If this disease occurs in a nearby village [and] animals roam around and (…) graze together, then our animals can also get this disease" (KB1a, Kalmati Baloch male livestock herder, Jungshai)
Around the time of movement, livestock keepers are particularly careful that their animals do not become infected, as this would restrict their movement for up to three weeks, until the animals have recovered. As respondents cannot afford to lose a sick animal, they invest in veterinary treatment, as “losing an animal is like losing a family member” (KB1b). Respondents are wary of public veterinary and health services however, and private veterinary and healthcare are sought, while prescribed medication is often mixed with traditional methods, such as burning herbs for their smoke to “cure the fever and mouth disease” (KB1a). Although healthcare in larger towns, and especially Karachi was considered better quality, respondents faced difficulties accessing healthcare, due to a lack of female health professionals and language skills, as many health professionals in the province do not speak Sindhi. With veterinary care being much more expensive than human healthcare, only one respondent mentioned buying vaccinations against FMD in the past, no longer having funds available for disease prevention. Milk is so precious that even milk from sick animals is used, posing potential zoonotic disease risk, which may explain the high prevalence of brucellosis in the region, which is mitigated by boiling for preservation purposes when possible.
Having escaped floods, the lack of sufficient quality water in drier areas is a health risk to both animals and humans during displacement. While a water pump was once installed by the Saudi owner of a falconry farm in the displacement location, its mechanical parts were taken away, and currently the community and their animals depend on surface water for drinking and washing. After political developments stopped the regular migration of Jati Baloch in search of water, they now depend on water trucking of brackish soiled water sourced only a few kilometers inland. Water is never boiled however, reflecting households’ lack of time and fuel, all increasing the risk of zoonotic disease transmission.
Community and livelihood disruption
Displacement, disease and the loss of animals severely disrupted people’s livelihoods and community. The Jati Baloch initially moved separately, based on personal networks and connections, before regrouping in their final destination. Some male youth migrated onwards independently to urban centers such as Karachi to find work. Kalmati Baloch communities and families are similarly divided between rural and urban centers, as the land they own is not enough for subsistence. During displacement this division deepens. While there is a strong ancestral connection to the land in both origin and destination location, households primarily determine their destination location based on the area best suitable for their own livestock. In the hilly areas, communities can count up to 100–300 households, each originating from much smaller origin villages, which increases the risk of zoonotic pathogen spillover between animals, as well as animals and humans.
Socio-economic status is a major determinant of health, with those with fewer resources at increased risk of disease, including zoonoses [
44]. As poor households depend on each other, the division of communities and households negatively affects mutual assistance and solidarity, increasing the risk of zoonotic disease.
“we borrow from each other, if someone has money, he gives to the ones who do not (…) we unite in difficult times" (KB1a, male livestock keeper, Kalmati Baloch, Jungshai)
Access to services during displacement are scarce. None of the respondents is connected to the electricity grid, although some households bought small solar home system on loan or through NGOs, however, there is no funding available for maintenance. This impacts the available time to cook and boil milk to eliminate zoonotic pathogens to limit the risk of diseases such as brucellosis. Some households have mobile phones, but the lack of reliable electricity supply means that these are used infrequently, which hampers access to mobile veterinary services, including vaccinations and treatment of potentially zoonotic diseases. Worryingly, none of the displaced children receives any education, which is the bases for improving socio-economic status, knowledge of diseases, and through this overall health status. Kalmati Baloch elders received some education, however, financial difficulties forced them to move to a remote village in Ghulamullah, where their children do not have the ability to go to school. In another Kalmati Baloch village, access to school for children from surrounding villages was blocked by the headmaster, as retaliation for a political conflict over the construction of a road to his land. While Jati Baloch elders also received up to four years of education, nearby schools in the Delta were closed eight years ago due to a lack of teachers.
Livelihoods are disrupted as floods destroy houses and crops, impacting protective shelter, and human food and animal feed supply, negatively affecting immunity against zoonotic disease. Even in regular times there is a lack of food, and “men have to leave early in the morning for their daily work with only one cup of tea to start the day” (KB2b). Owning only a few acres of agricultural land per household, daily wage labour is common among Kalmati Baloch, both in origin and destination locations, shifting from agriculture to construction labour when the fields become flooded. Even temporary displacement can last for up to three months, when no planting can take place, and livelihoods are further disrupted. Additionally, researchers found that the onset of monsoon rains has shifted forwards, with implications for the cropping calendar of rainfed agriculture [
45].
Animals are an important asset to the Kalmati Baloch, providing nutrition, food security, and even acting as collateral: "(if) someone sees animals standing at our home, they understand that [we] will return his money even if [we need to] sell [our] animals” (KB1a). They own small to medium size herds, consisting of 10–50 goats, cattle, and buffalo, with a generational shift towards cattle as these are considered ‘healthier’, although these are not highly productive: “a cow produces six to eight liters milk [a day], if they [would] receive extra feed, they could produce 16 L a day”(KB2a). Adolescent boys herd the animals during the day, while women take care of the livestock at home. Some cattle is owned in ‘partnership’, with the primary owner receiving a profit when the animal is sold, while other cows are rented by dairy farms in Karachi during their productive months. Animals are sold after 9–10 pregnancies, at a time when they still produce milk, to fetch the best price in the market, with some money reinvested in a cheaper, younger animal. Younger animals are only sold when “our life depends on [it]” (KB1a). The loss of animals cannot always be offset: one elderly female shared that two decades ago the household owned 20–25 buffalo, which were lost because of a “disease in their throat” (KB1b), with insufficient assets to restock. The lack of nutritious food affects immunity to zoonoses, while together these factors increasingly negatively affect socio-economic status, and therefore health.
The Jati Baloch have stuck to camel keeping mainly for their monetary value and as status symbol [
29]. Mangroves and the sea breeze are considered healthy for the camels,recently however, one Jati Baloch community lost about a dozen camels to a disease “from elsewhere through the air” (JB3a), after consulting veterinarians and self-administering medication. The last time that so many camels succumbed to a disease was over thirty years ago, a time when Kalmati Baloch shifted away from camel herding.
"our ancestors used to have camels as per our Baloch tradition (…) My maternal grandfather used to have 500 goats (…) and I too used to have goats (…) but then some diseases spread among them (…) three of them died in just one night and then I sold out the [other] one as well [and] I brought a gold nose pin for my wife out of that money" (male livestock herder, Kalmati Baloch).
Adolescent boys herd the camels on remote islands for over half the year, and the camel milk therefore only has a limited impact on a household’s nutrition and health status. As it takes half a day to reach these islands by boat, the boys cannot go to school, and sometimes even lack fresh water supply as bad weather or the price of fuel prevents supplies from reaching the island. The limited fuel available is primarily used for fishing, an occupation the Jati Baloch depend on since their permanent displacement, as agricultural land and livestock was lost, and while this has led to a reduced risk of zoonoses from livestock, respondents still consider this loss overall detrimental to food security, nutrition and health.
In the past two decades, around 7% of farmers in the Delta have abolished farming, with wider implications for the region and country’s food security [
46]. The decision to change livelihood or exit farming altogether is not an easy or straightforward one, instead depending on a combination of high input and low output prices, water shortages, and weather shocks [
46]. Respondents blamed upstream irrigation for their losses and deteriorating living conditions. Similarly, Jati Baloch blame salinisation on the lack of Indus river water, however, while they see the sea approaching, they are not preparing to leave again, as their “forefathers were buried here” (JB1a), and fearing the loss of their livelihood.
‘we are safe when we are near the river, if we leave the river there is no livelihood for us’ (JB2a, Jati Baloch male)
Prior to extensive waterworks upstream, the port city of Keti Bunder was reportedly a 'cosmopolitan coastal community', providing financial support to other cities, including Karachi [
14]. In the surrounding area, livestock husbandry, agriculture and forestry were primary livelihoods, with agricultural produce slowly shifting from rice to sugarcane to tomatoes, as fresh water became increasingly scarce [
14], impacting health status of both animals and humans, as well as contributing to deforestation and the loss of forage for animals. As a result of environmental degradation and increasing levels of intergenerational poverty, people migrated or reverted to fishing [
14]. Fishing requires significant and recurring investment in the maintenance of boats, fishing nets and other equipment however, forcing many fishers to obtain loans, which are difficult to repay as profits are limited by commissions charged by middlemen and auctioneers [
14]. Karrar describes fishing therefore as a 'credit driven industry with endless cycles of borrowing and repayment', in itself a form of feudalism similar to the landholding system common across the rest of the province [
14], and causing a deterioration in people’s socio-economic status, thereby in turn impacting health [
9].
As people diverted livelihoods to fishing, the mangroves briefly benefited from a reduction in camel grazing, however, the increase in marine fishing now threatens the sustainability of fishing resources instead [
29], impacting food supply, nutrition and immunity against disease. The communities witnessed a decline in fish stocks, with respondents complaining that some fishers continue to use small mash nets even though these are illegal, while respondents themselves are unable to fish at deep sea as their boats are too small. Disasters keep having significant impact on their livelihoods, and during our interviews, respondents were not allowed to go fishing following a cyclone alert by the Pakistan Maritime Security Agency (PMSA), losing much needed income.
The poverty spiral and impact on disease
"Difficulties… this world is full of difficulties. When it rained heavily [the village] became so dirty and full of mosquitoes [threatening] our children and animals (…) then when we came here we faced great problems too (…)" (KB1a, male livestock keeper, Kalmati Baloch).
Each displacement cycle, whether permanently inland or seasonal temporary movement, disrupts communities and livelihoods, increasing precariousness, and susceptibility to zoonotic disease. Zoonotic disease risk is dynamic however, for instance as livestock is lost to accidents, disease or sold to afford displacement, zoonotic disease risk decreases. Meanwhile the loss of assets and nutrition increases the risk to animal and human health, in particular when healthy adult livestock is replaced with new animals of unknown health status. Furthermore, losing livestock limits the ability to recover, with households spiraling further into poverty following each displacement.
Social capital in the district depends on 'the canal water availability, the drainage system availability, land holding, the farming experience and the family size' [
47]. Unsurprisingly therefore, the little socio-economic data available show that poverty among communities in the Delta is increasing due to environmental changes and degradation [
15,
29], with severe impact on health status. While the social determinants of health explain disease as a result of individual socio-economic risk factors, the ecosocial theory reflects better the situation in the Indus Delta, where structural inequality is embodied by ill health of both animals and humans. As people are getting poorer facing extreme hardship, they are stuck in a downward health spiral. Skin, respiratory, gastrointestinal problems and fever, including malaria, are considered ‘normal’ seasonal diseases:
"By the grace of God, everyone is almost fine. But things like fever are normal" (KB1a, Kalmati Baloch male livestock keeper)
One adolescent boy returned to his village after contracting typhoid fever while working in a garment factory in Karachi, with an outbreak of extensively drug-resistant (XDR) typhoid fever ongoing across Sindh since 2016 [
48]. After the initial medication did not cure the disease, there is no more money to continue treatment. Furthermore, infant mortality is high, with one respondent losing five out of their seven children. While the determinants of health describe the influence on health and disease as a result of a lack of healthcare access, lack of water/ nutrition, and substandard living conditions, the process which determines these risks is rooted in political factors.
While environmental displacement impacts health status, environmental degradation and the capacity to respond are rooted in political decisions, both at national and international level, as highly developed countries are disproportionally responsible for global pollution and climate change related impacts. In climate change policy development, the concept of 'climate suffering' is linked to loss and damage in an attempt to support mitigation and adaptation, including through migration [
26]. In this context, 'climate trauma' can be a direct result of disasters as well as being displaced.
"it is always the poor who suffer from floods" (KB2b Kalmati Baloch, female livestock keeper)
Due to the localised economy of the Indus Delta [
14], there seems to be little political interest in improving the lives of the coastal population, while the lack of coordination between overlapping and competing institutions mandated for coastal management hinders the development of sustainable policies and responses [
30]. Inequality rooted in colonialism has been exacerbated by structural adjustment programs (SAPs) forced onto Pakistan by international financial institutions, which continue to claim that the most efficient allocation of resources is one that maximises economic returns, even when faced with the detrimental impact of economic growth on climate change. SAPs have resulted in inadequate freshwater flows allocated to downstream ecosystems, which are considered as unproductive compared to irrigated agriculture [
11]. Furthermore, social healthcare practices were lost due to the enforced privatisation of public health structures. These developments have negative consequences for people’s risk of zoonotic disease, as these are influenced by the environmental changes as a result of climate change and disaster, the lack of access to (veterinary) healthcare and other services, and low socio-economic status described above.
The reduction of veterinary and public health services have led to an underfunded sector unable to comprehensively monitor and respond to disease [
49]. In Sindh, sero-prevalence studies are rare, and primarily conducted in large-scale farming contexts, rather than in areas where people rely on subsistence farming. Zoonotic disease data is often based on proxies such as ‘respiratory illness’ for tuberculosis and ‘dog bites’ are reported as rabies, while few cases are diagnostically confirmed. Data is stored in paper format in the archives of provincial government departments and links between datasets have not been analysed.
Rooted in a feeling of helplessness, respondents were discontent with their situation, location, the government, local health professionals, and deeply distrusted political elites, sometimes resenting those better off. Some respondents only participated in the study because the facilitator and translator belonged to their own tribe. Fishers blame illegal fishing on 'outsiders' who disregard local resources, backed by regional elites chasing after profit [
11]. The failure of the 1991 Water Accord is blamed on Punjab province, which is 'viewed with contempt because of its dominant and dominating positions in politics, economy and the military' [
17]. Respondents rarely interact with outsiders, only sporadically meeting NGO staff or healthcare professionals: "they come in this area just like you (…) [for instance] some agriculture people [told us which] sort of spray we should use for our crops" (KB1a, male livestock herder, Kalmati Baloch). No government assistance is received, except for the polio drops distributed by Lady Health Workers, a relatively successful scheme inherited from a more socialist era.
"the government does not care about human health, let alone animal health" (KB2b, Kalmati Baloch female)