Pakistan’s Covid-19 numbers have shown a positive trend in the last month, following more than six weeks of explosive growth after Eidul Fitr. These encouraging trends include a significant drop in test-positivity rates, and a decline in hospitalisations and deaths. This has been celebrated by the government with great aplomb, and televised victory speeches. It has been met with a mix of relief and caution by Pakistanis, amid concern about plummeting testing, and the approach of Eidul Azha.
The viral surge that followed Ramazan was unnecessary and tragic. It did not have to be that way. To date, more than 40 countries with varying GDPs, literacy rates, and population densities have used diverse methods to suppress the virus, never letting it reach the levels Pakistan saw in June. Their daily cases now stand between 0 and 50. Whether we follow in the steps of these "winning" countries, or fall back into infection spikes and lockdown-release cycles, hinges on what we do next. Instead of passing the baton of protecting their own lives to the people, the state’s pandemic response needs to change course. It needs to become proactive, urgent and aggressive. The absence of a science-informed containment plan will be measured in more human lives.
Four key interventions stand out as critical to keeping daily cases low.
1. Scale testing
This is the most essential and misunderstood piece. The chatter about a state conspiracy to keep testing low is merely a distraction — the real concern is that tinkering around with a handful of tests is a sure path to accelerating infection. Regardless of reason, and even with declining cases, testing less is never the right approach in pandemic management. Without widespread testing, we cannot isolate new cases, particularly the asymptomatic, pre-symptomatic or mildly symptomatic ones, and without isolation we cannot stop the spread. Testing is the only way to make the disease visible and control it.
Pakistan is neither testing enough relative to its current outbreak, nor does it seem prepared to ramp up testing in case of a new surge. In the past week, it averaged 21,627 daily tests for a population of 220 million. This is less than half the mimimum testing advised by WHO in its June letter to the Health Minister. It is also roughly one-third of neighbouring India’s per-capita testing, even though our per-capita cases still remain 20 per cent higher than theirs.
We are told that testing has gone down because demand for it has decreased. While lab owners have confirmed this decline in voluntary testing, the key issue is this — waiting passively for people to show up for tests is not how disease surveillance and control works. The "winning" countries, including low-income ones, all engaged in proactive search and detection of cases. They continued to ramp up testing as spread slowed down, so that new cases could be contained quickly. This allowed them to stay ahead of the curve, while we continue to lag behind, playing catch-up with a raging fire.
The Ecuadorean city of Guayaquil recovered from being a Covid-19 hotspot by using mobile medical brigades that went into the hardest-hit neighbourhoods to test and isolate. In Cuba, door-to-door search for carriers, and assisted isolation of the sick and suspected cases kept total cases under 2,500. In Ethiopia, community health workers screened 40 million people to contain the spread. In other words, testing is not meant to be a passive process.
Demand for testing must be grown by increasing community engagement, and re-establishing trust between the health system, the state and citizens so that consensual testing becomes commonplace. Instead of denying that more testing is needed, public leaders should communicate it as an urgent state goal, so that citizens understand the role of testing in pandemic control, along with their own role in enabling it. Excess capacity should be deployed in high-risk populations such as health staff, frontline workers, prisons, crowded communities, or to test suspected cases and contacts. While we are told Pakistan has the capacity for 80,000 daily tests, this has not resulted in actual tests due to deficiency in staff, PPE, supplies and equipment. Scaling all of this infrastructure in anticipation of future spikes should be priority.
Testing should go hand-in-hand with quick turnaround times and assisted isolation — two key elements without which testing is ineffective in controlling spread. These were missing in Pakistan in June, when turnaround times surpassed a week, and fear and mistrust kept infected individuals away from isolation facilities.
2. Identify and limit super-spreader events
In order to control the virus, we must identify Pakistan’s active infection clusters and super-spreading events. These are the settings and conditions that have played an oversized role in contributing to the country’s caseload. Dozens of epidemiological studies, research on actual cases and models of the pandemic show that 80% of the infection is caused by 10 to 20% of Covid-19 carriers, at super- spreading events. These are incredible statistics. They mean that if we could stop these events, we could crush the curve and stop the pandemic. We now also understand the conditions that lead to these clusters. They occur when there is an overlap of the three Cs, which are: closed spaces with poor ventilation, crowds, and prolonged close-contact settings such as close-range conversations.
Identifying and strictly controlling these high-risk settings is so disproportionately effective in controlling spread that it has emerged as the key to controlling Covid-19. And failing to do so has led to fresh waves for countries like Israel, which brought daily cases to under 10, before going back to 2500 per day.
In this context, it is curious to see a stream of global news about super-spreading events — meat-packing factories in Germany, church gatherings, food processing plants and prisons in the US, weddings in India, bars and gyms in South Korea, schools in Israel, karaoke parties in Japan, prisons and nursing homes around the world — but no such stories about Pakistan. This is not because we have not had any super-spreading events, but because we do not trace, identify or bring them into the public domain. On the contrary, public leaders have made unscientific claims about high-risk settings such as mosques not having led to any cases. This is harmful conjecture. Instead, we need to trust the science of Sars-Cov-2 transmission, and limit or ban settings that are breeding grounds for it. The post-Ramazan viral explosion can also be explained through this lens, in light of the large religious congregations, crowded malls, indoor family gatherings, Iftaar and Eid parties, and funerals that took place throughout the month. This created a tsunami of clusters that took over a month to die down.
If rules are not imposed to limit super-spreader events, and investment is not made in surveillance and tracing to identify clusters, it will only be a matter of time before cases spike again.
3. Get the public on board
There is a dire need to get the public on board, regain lost trust and get the messaging right. Without this, there can be no compliance around testing, tracing, or containment, and repeating the "strict SOPs" mantra only offers false security. Our leaders need to send a unified science-informed message to the nation. They must take responsibility for the weight of their words, and their role in creating public motivation or complacency, which drives transmission rates. In this context, posturing cannot be ahead of reality, because public vigilance is based on perception of threat. We need full honesty, both when trends are positive but more critically, when they are negative. So far, the state’s response has gone from denial in March and April when there was a real window of opportunity to suppress the virus, to apathy and nihilism in May and June as cases spiraled out of control, to premature and overblown declarations of victory this month as trends improve.
Getting the public on board requires putting richer data regularly in the public domain to inform and motivate. Daily, regional growth rates and trends for core metrics such as hospitalisations, ICU admissions, test-positivity rates, testing turnaround times, hospital capacity and R0 should be easily accessible online. These can encourage the public to practice caution in accordance with risk levels in their district, and to share in the victory when trends are positive. If people can see the metrics on which risk classifications and state decisions are based, trust and compliance will be higher. Greater transparency will also help build faith that the government is serious about protecting citizens’ lives and livelihoods.
Getting the public on board also requires accurate and simple science communication about important topics such as modes of transmission, asymptomatic spread, immunity and masking. This communication should evolve with new evidence, and be nuanced enough to take into account the fact that the risks associated with people’s everyday decisions lie on a spectrum; they are not binary.
4. Have reopening benchmarks
We need benchmarks and a risk-informed plan for a safe reopening. The most striking thing about Pakistan’s pandemic response is the absence of any targets or benchmarks in the public domain. Targets are not reported numbers, but thresholds that we are aspiring to. What levels of community transmission will make it safe for schools to reopen? What are our national targets for testing? What is our R0 at present and what should it be? What test-positivity trends over what time period are needed for indoor businesses to operate safely? What regional hospitalisation trends will keep health capacity at safe levels? Surveillance systems should rank districts on infection severity, allowing them to move between green, yellow and red, with corresponding mobility rules and reopening plans. Setting dates for reopening regardless of transmission levels, as is currently being done for schools, is tantamount to saying we have given up on protecting citizens’ lives and livelihoods. Reopening is meant to be a phased process rooted in public-health-backed, clearly-defined benchmarks. Pakistan’s patchwork reopening thus far has followed no rhyme or reason, let alone be informed by benchmarks.
Clearly-defined benchmarks are vital not only for managing the current outbreak but also for detecting and preventing future outbreaks. Knowing when to allow more mobility and when to practice more caution is an exercise that will need to be repeated over and over again for the next eight to 12 months, until the test-trace-isolate infrastructure is so robust that new cases fall to single digits, or there is a vaccine.
In summary, Pakistan needs a containment plan that includes these four factors: widespread testing with assisted isolation, identifying and limiting super-spreader events, getting the public on board, and clearly-defined reopening benchmarks. In the absence of these factors, the pandemic will continue to put our most vulnerable and marginalised citizens at the highest risk. As Pakistanis, we must ask for more from a government that came into power on the promise of protecting its disadvantaged citizens.