HOW one wishes there was a team of competent modellers in Pakistan who could present the worst-case (do-nothing) scenario, the most likely response given the existing state of affairs, and the best-case outcome if appropriate measures were put in place.
I say this after the model run by London’s Imperial College became decisive in drastically changing public policy in the UK. Unfortunately, it is not the case, one to which we are addicted, that a foreign model can be imported and run here to determine our choice of public policies. Too many parameters are different and would need to be normalised to our circumstances.
Take the most obvious one first. The degree of compliance with directives is much lower here than in the UK — I walked past a padlocked park where the ground staff were huddled together under one canopy sharing a cigarette. Citizens do not trust the government for any number of reasons. If asked to be tested, their first tendency is to run as far away as possible for fear of what might be done to them. This trust deficit now runs so deep in our society that no one takes anything at face value. Add to that the many who consider themselves answerable to an authority higher than that of the state and wish to pray together at any cost.
The age pyramids of the two populations are entirely dissimilar, making a huge difference in expected mortality risks. Then there is the specificity of the labour force. There are virtually no footloose workers in London; there were many migrants in Wuhan, but they were adequately housed and in no need to flee home — in any case, they would not dare disobey state directives. Here, millions work in cities, while their families are in villages. Many literally sleep on the streets. How they would respond is apparent from what happened in India, something policymakers were either oblivious to or not bothered about.
We are not even clear about the primary objective of our policy.
Given all such unique conditions, what does a lockdown, which can be leaky, yield? What does social distancing mean when two-thirds of the urban population lives in houses with six to eight persons per room? How does personal hygiene work when there are people who cannot afford soap and do not have access to more than two cans of clean water? The modellers would have to cater to all these peculiarities before they could give us any sense of what to expect in Pakistan.
In addition, it is just not enough to run a model once. It needs continuous recalibration based on cumulative data. Is April really going to be the cruellest month — Italy with a lag — or is something actually going on that is different, with infections, however flawed their measurement, growing exponentially, while deaths, much harder to hide, showing a flatter trend?
Right now, we are not even clear about the primary objective of our policy. Is it to minimise the number of deaths at any cost — in which case, a model made by epidemiologists, virologists and behavioral scientists might be enough? Or is it to minimise the number of deaths at least cost, in which case, public health models need to be complemented by ones that match each scenario with estimates of the accompanying socioeconomic impact?
This trade-off is not as simple as it seems because of complex interrelationships — saving the old from infection can mean sacrificing the young to starvation. We have heard from the government that 25 per cent of households cannot afford two full meals a day. There are certainly just as many who can barely achieve that luxury, which immediately raises the question: how long can a lockdown be sustained in these circumstances before more people die from lack of food than from an infection? Already, there are reports of societal fracture with people pushed to begging and stealing.
Once again, this suggests that a Wuhan-type lockdown, no matter how desirable, might not be the affordable choice for Lahore or Delhi, and better adapted solutions might be called for. Given that, unlike the flu, corona infections are concentrated in clusters, the experts might suggest selective lockdowns of hotspots like Raiwind and Bara Kahu. The at-risk elderly might, on request, be protected in empty hostels, instead of crippling mobility across entire cities. To mitigate the incremental risk, the experts might stress universal use, through free distribution, of masks whose production can generate employment while being decentralised.
In any case, a lockdown is not a solution because the virus does not disappear. It only buys time in which other necessary measures need to be put in place. If they are not, the virus would spread again once the lockdown is relaxed and probably wreak worse havoc on a desperately stressed and famished population with depleted resistance. These other measures include extensive free testing, identifying hotspots, rigorous tracking, isolation, and quarantine. Experts in GPS techniques and information retrieval could help in guiding these tasks.
This is a truly unique situation in which no one really has all the answers. The last thing we need is for everyone to turn into an expert and start doing what appeals to their guts. Like gynaecology or oncology — in which no one would allow laypersons to interfere — public health and systems analysis also have their own specialists. We owe it to the people to get the best scientific advice possible and tackle this crisis in a way that makes sense in our country.
There is no reason that local institutions with relevant expertise, like AKUH, Lums, ITU and Nust, cannot put a team of experts together — not just for this emergency, but for the continuous surveillance of all infectious diseases. And there are many that still plague this country.
The huge number of preventable deaths in Pakistan at which no one bats an eyelid is a damning disgrace for which our governments are accountable. The ongoing tragedy should sensitise us that we cannot sustain much-needed lockdowns because of the conditions in which the majority is condemned to live. The injustice cannot be tolerated any longer.
The writer was dean of the school of humanities and social sciences at Lums.
Published in Dawn, April 13th, 2020