Widespread flooding in Pakistan affected millions of people and caused a significant humanitarian disaster with widespread economic and security consequences for the country. A stable, democratic, prosperous Pakistan actively combating religious militancy is considered vital to U.S. interests. The humanitarian effects of the flooding along with its security consequences generated considerable concern in the United States and many countries around the world. The flooding in Pakistan, which started in late July 2010, reportedly affected over 20 million people. Over 1.9 million households were destroyed or damaged. Approximately 2,000 people died and over 3,000 were injured. In terms of affected persons, the humanitarian impact of the 2010 floods in Pakistan is estimated to be larger than other recent natural disasters experienced globally. The estimated 20 million people affected by flooding in Pakistan is more than the estimated number of people affected by the 2010 earthquake in Haiti, the 2005 tsunami in the Indian Ocean littoral region, and the 2005 South Asia earthquake combined. The death toll increased after floodwaters receded in some areas, although specific number of deaths directly attributable to flooding is difficult to ascertain. Lost shelter and food staples, limited access to clean water, and unsanitary conditions from standing water and submerged lands are immediate humanitarian issues. Cases of malnutrition, gastroenteritis, diarrhea, skin infections, cholera, typhoid, malaria, and hepatitis have been reported. The Pakistan government established a National Oversight Disaster Management Council to improve the transparency in the distribution of flood relief. However, humanitarian relief efforts were tempered by initially low levels of donations, difficulties in accessing victims, the large geographical extent of the disaster, and security concerns in some regions. Some medium and long-term consequences of flooding have been projected. Lost livelihoods for farmers (e.g., not being able to plant next season's crop) and a diminished food supply is a key concern. The flooding destroyed crops, food stockpiles, livestock, seeds, structures, and equipment. Food prices dramatically increased since the flooding, putting an economic strain on the entire population. Rebuilding damaged and destroyed housing is also expected to affect the return of displaced populations. As tensions mount and the struggle to stabilize persists, public confidence in government efforts to provide assistance will be tested. Long-term consequences such as damaged infrastructure (e.g., bridges, roads, electrical plants, and schools) are also expected to hamper recovery efforts and have a lasting effect on the country. Before the flooding, top-tier U.S. concerns regarding Pakistan included regional and global terrorism; stability in neighboring Afghanistan; domestic political stability and democratization; nuclear weapons proliferation and security; human rights protection; and economic development. The 2010 floods have exacerbated these concerns. The effects of flooding on the stability of the Pakistani government and its ability to suppress and contain militants within their borders is an issue of concern for the United States and others. Congressional interest regarding the 2010 flooding in Pakistan stems from multiple factors, including the U.S. response to the humanitarian needs of flood victims, potential cost of reconstruction after the flood subsides, the composition of aid given by the United States to Pakistan to garner its support for U.S. operations in Afghanistan, the disabling of Taliban inside Pakistan's borders, and the security concerns arising from a weakened Pakistan with a potentially disenfranchised and dissatisfied population. Public opinion surveys in Pakistan before the floods present two issues of concern for the United States: (1) that the percentage of Pakistanis polled who are worried about extremist groups taking control of Pakistan has declined from 69% in 2009 to 51% in 2010; and (2) that about 68% polled view the United States unfavorably. These numbers are expected to change after the floods as perception of a weak government grows and pressure to contain militants softens (see later sections of the report for more details). The United States, however, has an opportunity to improve its perception among Pakistanis. While humanitarian benefits are the priority, emergency aid and reconstruction efforts, if successfully implemented, may provide long-term diplomatic benefits for the United States in Pakistan. One potential issue for Congress and the Obama Administration is deciding what additional actions and funds are available, warranted, and effective. Many have suggested potential actions to address flooding in Pakistan. Some of those actions include Additional U.S. emergency relief funding, equipment, and supplies U.S. efforts to promote contributions and cooperation from other nations for emergency response and reconstruction Actions intended to support the Pakistan economy and trade Debt relief Efforts to promote individual and corporate aid and contributions Measures to promote foreign-direct investment and public-private partnerships Heavy rains associated with monsoons began around July 22, 2010, and led to flash floods in the northwest and east of Pakistan. (See Figure 1 .) Downpours continued for the rest of the month and persisted into August. The runoff caused the Indus River and its tributaries to breach levees and overflow into floodplains housing both rural and urban populations. At times river flows reached 40 times their normal levels. As floodwaters moved downstream, new areas of flooding emerged in southern provinces, such as Sindh. Intentional levee breaks were made in attempts to protect urban centers (e.g., Hyderabad); nonetheless, levee breaches affecting populations clusters (e.g., Thatta city) were still occurring in early September. The effects of the flooding covered a large geographical area in Pakistan and affected several provinces. (See Table 1 for September estimates.) The timing of the flooding effects varied for provinces. For example, in many affected regions in the north (e.g., Punjab and Khyber Pakhtunhwa provinces), affected populations have largely returned to their damaged communities and started rebuilding. However, in the south, such as in the Sindh province, stagnant floodwaters are preventing recovery, and significant displaced populations exist as of November 2010. It is reported that nearly 7.0 million people are affected by floods in Sindh province, with thousands trapped by flood waters and in need of assistance. Areas inundated weeks after the onset of flooding suffered significant agricultural and property losses, and concerns about food, shelter, safe water, sanitation, health, and livelihood persist. The response of the Government of Pakistan to the flooding is being organized at the federal, provincial and district levels. The Economic Affairs Division (EAD) is coordinating donors and the Pakistan National Disaster Management Agency (NDMA) is responsible for overall coordination of disaster response efforts by both the government and the international community. The NDMA works closely with federal ministries, government departments, the armed forces, UN agencies and donors to mobilize, receive and deploy relief goods. Relief activities are also being coordinated by provincial-level and district-level governments. The primary Pakistani response to the flooding was initially and has continued to be from the military. The military moved its forces and equipment into the flooded regions to evacuate people and distribute supplies. The civilian government response was reportedly weak, due in part to the damage and destruction of local governmental assets and properties during the flooding. Some also blame coordination issues for a slow state response, such as the absence of civil-military coordination and ineffective civilian control over military-led efforts. There were several reports of widespread criticism by the Pakistani people of the civilian government response to aid flood victims. Some, however, have defended the agency by stating that it was not structured to cope with a disaster of this magnitude. To help families rebuild, the Pakistani government is distributing debit cards to affected families. The Pakistan National Database and Registration Authority has distributed debit cards to over 900,000 families as of September 2010. They aim to provide $1,150 dollars to each head of household in three separate disbursements to help families recover from the floods. Steps are being taken to include female-head of households in the process for those females who lost their husbands. The United States is the largest donor of funding for relief efforts related to the flooding in Pakistan. Some funds are being converted from a portion of the civilian economic development assistance authorized by the Enhanced Partnership with Pakistan Act of 2009 (EPPA 2009, P.L. 111-73 ), which is appropriated primarily within the FY2010 base and supplemental appropriations ( P.L. 111-117 and P.L. 111-212 respectively). To date, the United States is providing a total of $561.9 million for Pakistan relief and recovery, largely coming from International Disaster Assistance (IDA) and Food For Peace (FFP) funds. (See Table 2 .) In-kind civilian and military support, such as the pre-fabricated steel bridges, halal meals, and air transport, amounts to another $89.1 million, according to USAID. Prior to the flooding emergency, the United States provided humanitarian aid to Pakistan to address the January 2010 landslides, conflict-affected displaced people (referred to as complex emergency funds), and pre-2010 earthquake expenses. (See Table 3 .) A potential issue for Congress is whether the purpose of these funds, as well as the authorized economic development funds from the EPPA 2009, should be changed to reflect flood relief efforts and changed circumstances caused by the flood. If the funds are redirected, then there could be concerns as to how the original objectives of the funding will be met. The United States Agency for International Development (USAID) is leading all U.S. government humanitarian response efforts to Pakistan. Nearly 30 U.S. military helicopters and four C-130 planes were involved in delivering humanitarian supplies. These included emergency food supplies, plastic sheeting, inflatable rescue boats, concrete-cutting saw kits, shelters, blankets, water storage bladders, and water filtration units among other things. Twenty-six U.S. mobile medical teams were providing health care services, which were needed because about 450 health facilities were destroyed or damaged by the floods, according to OCHA.