THE world has indeed turned upside down. In a mere 12 weeks, the novel coronavirus has led to the first pandemic in over a century. Pakistan was caught unprepared. Despite the outbreak in Iran, there was a lack of appreciation of the volume of land travel between the Iran and Balochistan borders. Facilities to screen and quarantine potential carriers were negligible.
With limited diagnostic facilities initially, the first cases of Covid-19 infection were detected by the public health system early last month. To date, nearly 70,000 tests have been conducted, but few of them have been in the general population and after over 5,000 cases and 86 deaths, we still don’t know the true extent of the problem.
Community transmission is now established across the country.
The subsequent response by the federal and provincial authorities was robust but uncoordinated. The Sindh government led with compulsory school closure and imposition of social distancing, followed by a lockdown.
In contrast, the federal government vacillated in terms of policy guidance, especially over restrictions on gatherings like Friday prayers. This costly mistake is likely to have accelerated the spread of Covid-19 in rural areas.
The prime minister finally addressed the nation on March 17 and while he was reluctant to introduce stringent measures, he focused on provision of support for families facing food insecurity.
This initiative, coupled with philanthropy, is why Pakistan has escaped the massive displacement of urban poor, as seen in India.
There has been disinformation about the nature of the pandemic. This includes speculation that the virus in Pakistan is somehow not as lethal as it is in the West and that the country may be spared the havoc seen in neighbouring countries.
Others believe that this may be related to our relatively younger population and the potential mitigating effect of the summer. None of these theories stands the test of scrutiny.
The growing number of deaths and serious cases of illness in the country suggest that we may be at an early stage of the epidemic, with an upsurge expected in the next few weeks.
One can understand the dilemma the government faces. It has tried to quickly fix the broken public sector health and has rolled out a massive $1 billion cash transfer programme to help 12 million people.
This is an estimated increase of five million women to the estimated seven million recipients of the Ehsaas Kifalat programme.
One can quibble with the strategy of dispensing funds through 18,000 outlets, making a mockery of social distancing rules. But this audacious yet timely safety net could well have quelled the inevitable social unrest that follows food insecurity and hunger.
It is, however, difficult to imagine how this programme could continue amid prolonged lockdowns. Pakistan thus finds itself at a true Morton’s fork with limited choices.
This is also where the government has failed to engage civil society and academia in a meaningful discussion of disease projections.
While the government has been working on assumptions of case burden and its implications for the health system’s response with critical care beds and ventilator needs, none of these projections or potential models has been put out for public debate.
Sadly, few academic groups have the capacity to produce such models and put these out for peer review. Our group has worked on such projections and it predicts that if allowed to continue unchecked, the coronavirus could kill over 700,000 Pakistanis. But mitigation strategies could reduce critical illnesses and deaths to 2,000.
However, to do this we must address the challenge of the next few months on a war footing. The patchwork of policy options currently being debated endlessly in the media and parliament must be replaced with a solid action plan.
What might these policy options be moving forward?
i) There is a need for unity to end the interminable bickering. Since Pakistan is a federation, the action lies with provinces.
The energy wasted on criticising each other in the media only serves to confuse and demoralise the nation. We need a non-partisan response.
There is no reason why every initiative must carry the prime minister’s name. In fact it shouldn’t.
Every provincial government and all political parties must join hands in the response as we would do in a state of war.
ii) Reinforce all preventive measures like social distancing and isolation. The continuing images of gatherings show that civil society engagement and community buy-in has been suboptimal.
The failure to forge consensus around religious gatherings could cost us dearly.
This threatens to become worse with the arrival of Ramazan. A clear strategy for avoiding Taraweeh prayers and communal Iftar is needed.
iii) We need much better preparedness across both public and private sectors. We cannot right the wrongs of decades by procuring ventilators alone in an impossibly short period. It can be argued that many district establishments lack basic facilities, e.g. the ability to monitor vital signs and provide oxygen.
These basic gaps in infrastructure must be fixed. It is important for provincial governments to enhance staff training and emergency transportation.
The public sector cannot do this alone without engaging the private sector and care providers.
iv) We should be better informed. We must obtain population-based granular and reliable data on infections as well as immunity, based on a more aggressive testing than the average 1,500-2,000 daily tests being done at present. These must include random population sampling to determine true prevalence and population immunity.
v) Don’t snatch defeat from the jaws of victory. We need to stay the course on social distancing and avoid premature relaxation for the next three to four weeks.
Once we are past the projected peak of the pandemic, we can reopen the economy in phases by allowing selected sectors to function and first deploying our younger, low-risk workers.
Finally, this crisis should open our eyes to the need for investment in national security and human development. For a nuclear state to not have robust investments in education, science and a functional disease early warning systems is unacceptable.
Pakistan loses an estimated 250,000 newborn babies every year, many for lack of facility-based care, including the same capacities that we need for Covid-19 management today.
It is tragic that it should have taken a pandemic to remind us of this.
Professor Zulfiqar A. Bhutta teaches at the Aga Khan University and is the founding director of its Centre of Excellence in Women and Child Health
Published in Dawn, April 14th, 2020