The coronavirus in Pakistan has public health experts stumped. At the end of May, the South Asian nation of over 220 million people faced disaster. With limited health services, widespread poverty, and a population that largely lives in crowded cities, global health officials feared Pakistan would be one of the countries worst hit by the deadly virus.
These fears seemingly came true in mid-June this year when the daily number of reported cases jumped to nearly 6,000. To make things worse, a study published by the Imperial College London predicted around 2.2 million deaths in the coming weeks. The federal government, in turn, was hesitant to impose a country wide lock-down despite this alarming forecast, proposing, instead a “smart lock-down” strategy which targeted virus hot spots in urban areas.
By the end of August, however, Pakistan’s active number of cases had fallen drastically with the number of new daily reported cases decreasing to around 500.
Source: World Health Organization “Pakistan: Coronavirus Pandemic Country Profile” (https://ourworldindata.org/coronavirus/country/pakistan?country=~PAK)
What do we know? What don’t we know?
There have been various explanations for Pakistan miraculously eluding the worst of the virus. They mention, to varying degrees, a preexisting public health infrastructure, natural immunity (due to “cross reactivity” stemming from exposure to previous coronavirus-like diseases), a coordinated and innovative government response, and environmental factors like climate and population age.
I spoke to Arman Majidullah, a public health expert based in Karachi, Pakistan to shed light on Pakistan’s COVID-19 conundrum:
The big picture.
Here are three main takeaways from my conversation with Arman:
There is little causal evidence of natural immunity in Pakistan either from genetic sources or exposure to similar viruses in the past. An anecdotal glance east to India shows a country that has a similar “disease burden” to Pakistan (setting aside polio) – hence a population that is likely to have the same immunological response to COVID-19. The rising rate of coronavirus infections in India suggests natural immunity might not be a large factor in Pakistan (though it is important to note that India is a far larger country and talk of cross-reactivity – given the lower than expected mortality rate – is common there as well).
Pakistan’s experience with previous diseases had little effect on COVID-19 preparedness. Perhaps the most shocking aspect of the pandemic is its disproportional effect on richer countries like the United States rather than poorer ones with limited resources. But, having experienced outbreaks of infectious diseases like Ebola, countries like Liberia have a preexisting infrastructure geared toward controlling virus outbreaks. The same is not so for Pakistan whose experience with polio – a disease that largely affects small children – cannot be scaled to address infectious diseases.
All that being said, coordinated public health interventions early on did work. Government bodies, NGOs, and hospital networks were quick to come together according to Arman. Two clear examples of this were
i) A sustained and consistent public messaging program, delivered through widely accessible technologies like cell phones, that warned people of the severity of the virus as well as information on testing and prevention.
ii) The centralization of virus monitoring and screening – two primary tools in a coordinated public health response. Decentralized data set collected by hospitals were synchronized and given to a federally-run virus cell which then identified hot spots and created policies, thus possibly enhancing the impact of smart lock-down strategies.
The way forward?
As Arman mentioned, the evidence public health experts have is anecdotal. In other words, the health sector cannot confidently say what did or didn’t cause the coronavirus trends we see in Pakistan. This has two humbling implications. First, explanations for a lower infection rate in Pakistan are incomplete and it is unlikely that the country’s experience can be replicated elsewhere until experts get a clearer picture of what happened. Second, it is difficult to predict whether Pakistan will face a second wave in the months that follow. This is more worrying given that the country has largely returned to normal, with social distancing becoming individualized to families and businesses. What is clear, however, is that with 315, 512 cases at the time of writing, the threat of a delayed public health catastrophe remains very real indeed. For now, Pakistan, like many other countries, is simply learning to live with the coronavirus.
Episode 1: Pakistan's Coronavirus Conundrum