By Tilak Devasher
The first case of coronavirus was reported in Pakistan on 26 February 2020 in Karachi. Thereafter, it spread to all the four provinces, the federal capital, so-called Azad Jammu and Kashmir (AJK) and Gilgit-Baltistan (GB).
The main sources of the initial spread were the pilgrims returning from Iran and the Tableeghi Jamaat congregation in Raiwind. However, by 31 March the government estimated that a good 27 per cent of the coronavirus cases were the result of local transmission. This figure of local transmission went up to 58 per cent by mid-April.
While no country was prepared for such a catastrophic event, in Pakistan the crisis has been compounded due to the healthcare system being in shambles- barely capable of meeting even basic requirements of its growing population, let alone rising to a daunting challenge. As the Minister for Planning and Head of National Command and Operation Center (NCOC), Asad Umar warned on 05 April the coronavirus cases were expected to touch the limit of the health system in the next few weeks despite the low spread of virus. Imran Khan has also warned that outbreak could take a turn for the worse by the end of April that will put more pressure on hospitals.Such a situation has largely been the result of woeful investment in the health sector for decades by successive governments.
The coronavirus infection is growing exponentially with over 9500 positive cases and over 200 fatalities as on 21 April. However, in such situations statistics are out-dated by the time they appear in print. Moreover, the numbers themselves could well be under-estimated given the limited capacity to track and test the infection as also the fact that thousands of unscreened people have gone back to their communities. Consequently, the escalation in the number of cases, despite extremely low testing rates potentially presages a forthcoming peak of confirmed cases and fatalities that could well overwhelm the health care system and Pakistan’s capacity to deal with.
The following are some of the disturbing trends that have emerged so far.
The federal health ministry in a report to the Supreme Court, on 04 April submitted that coronavirus infections in Pakistan may rise to 50,000 by 25 April – a projection based on the pandemic’s trends in other countries. Some 2,392 of these infections might be in critical condition; 7,024 in severe condition and 41,482 mild infections. By the third week of April, however, this estimate had been scaled down to 15,000 positive cases by end-April with 50,000 cases being expected by mid May.
The Special Assistant to Prime Minister (SAPM) on National Health Services (NHS) Dr Zafar Mirza on 01 April revealed that the number of suspected coronavirus cases in the country was increasing at an average of 12 percent. According to him, the number of suspected cases had surged to 17,331 and 1436 new suspected cases were registered in the last 24 hours.
The Sindh government’s spokesperson Murtaza Wahab on 07 April stated: “Pakistan’s got its 1st COVID-19 patient on 26th February. We got our 1,000th patient in 29 days; the 2,000th patient in 7 days, 3,000th patient in 5 days and probably the 4,000th patient in 3 days. This is how serious the situation is.” According to another calculation made in the third week of March, the number of those infected doubles in six days if not controlled. ‘Assuming there are 400 infected today (21 March), there will be 102,400 people infected by 06 May; 15,360 of these will need hospitalisation and 5,120 will need ventilators.
These figures show that the country is entering/has entered the exponential-growth phase. What makes the numbers even more alarming is that the number of tests conducted in the country was only 39,183 till 07 April with the current testing capacity standing at 3,088 per 24 hours. Of those tested nearly 10 per cent had been positive. According to Dr Zafar Mirza testing capability would be enhanced by the end of April. He said: “Earlier around 800 tests were being conducted daily but for the last few days we are conducting 2,500 to 3,000 tests a day. By the end of this month, we will hold up to 25,000 tests daily.” Out of a total population of about 220 million, only 55,000 had been tested since February to mid-April.
Meanwhile, urging authorities to ramp up testing Dr Ma Minghui, the deputy director general of the Xinjiang Uygur Autonomous Region Medical Products Administration and the head of the Chinese medical team that visited Pakistan told the media that “In Pakistan, one out of every 10 person tested for COVID-19 up till now has returned a positive report. This is much higher than Xinjiang, where only one in 100 people tested for the virus reported positive.” She also warned that the possibility of the outbreak in Pakistan could be far bigger than the confirmed numbers show. “Unfortunately, Pakistani authorities are fighting this virus in the dark right now… the shortage of testing kits and reluctance of citizens to come forward for testing may be masking true numbers. And you cannot contain COVID-19 until you have a clear picture,” she added
An intriguing development is the spike in the number of dead or near dead being brought to hospitals in Karachi’s different hospitals/graveyards. According to one report, a total of 3,265 dead bodies were brought to 30 graveyards of Karachi between February 20 and April 9 (49 days). This has raised fears that the number of Covid-19 fatalities could be much higher than being reported. However, there has been no official confirmation and no hospital was reported to have conducted tests to ascertain whether the real cause of death was Covid-19 or not.
According to another report, two hundred-odd deaths in Karachi, in two weeks’ time are just about normal. However, the figure has risen in the past few days. During a recent TV interview, Dr Seemi Jamali, the Director of Jinnah Post-Graduate Medical Centre (JPMC), Karachi’s biggest public-sector hospital, said that over the last 15 days, there has been a 21% increase year-on-year in the total number of patients either brought dead or dying within hours after arrival. Most of these patients were suffering from ‘pneumonia-like symptoms’. His account has been substantiated with the Edhi Foundation stating that the number of bodies received at their mortuaries in Karachi between April 1 and 13 was 388 as against 230 bodies received during the same period last year. This showed a significant increase of 158 deaths. The cause of death of those brought dead or expiring within hours of arrival at the JPMC hospital, however, remains officially unknown since no post-mortem was reported.
However, a few such deaths — i.e. those happening on arrival or hours later — at Indus Hospital, a privately run hospital, has raised alarm. According to the CEO of the hospital during the last couple of days, four people were brought to the hospital both dead or nearing expiry and all of them were found to have contracted the coronavirus. That such deaths may have also been happening at other hospitals in the city — in fact in the entire country — cannot be ruled out. While the official coronavirus death toll across the country stood at over 200 on 21 April, the number of deaths with unknown cause does raise a big question mark on the authenticity of the official figures. The only way the issue can be resolved is if all hospitals across the county test patients brought to the hospital dead or nearly dead for the coronavirus in order that the actual number of deaths from the pandemic could be ascertained.
This situation in Karachi led Murad Ali Shah, the chief minister of Sindh to state that he feared that the actual number of deaths in the province was probably much higher than what was being reported. His suspicion was that many cases with “pneumonia-like symptoms” were simply going undetected.
Two reasons could account for this situation. First, according to a recent Gallup International survey carried out in March 2020 as many as 43% of all Pakistanis had not taken any precautionary measures to protect themselves from coronavirus. The survey declared this as the highest percentage of citizens among the 28 nations that took part in the poll. According to another survey carried out by the Aga Khan University (AKU), less than one in 10 rural residents correctly identified being in crowded areas as a factor for getting infected. Moreover, 74% of the rural sample incorrectly believed mosquito bites to be a cause of the global pandemic.
Secondly, there have been several major quarantine lapses. For example, a group of 252 pilgrims that came from Iran on 29 February was allowed to leave the Taftan Corona Quarantine centre without completing the mandatory fourteen day quarantine. Then again, over a thousand pilgrims who had arrived in Multan on 20 March from Iran via Taftan and had earlier tested negative for the virus have since contracted the disease — a result of the poor quarantine conditions in which they were detained in Multan. What has compounded the lapse is that during detention they interacted freely with infected patients housed in the same facility and then were allowed to return to their home districts.
Two other issues have compounded the problem. One is the dire shortage of protective equipment for doctors and medical staff. Despite this, footage and photographs of President of Pakistan Dr Arif Alvi wearing an N-95 mask at a meeting sparked serious criticism in the health circles especially when viewed against the backdrop of doctors in Quetta demanding the protective gear being thrashed by the police and being arrested.
The second is the issue of daily congregational prayers in mosques. The initial government policy was to restrict such congregations to five or less persons. Sindh went ahead and declared a curfew from 12 to 3 pm on Fridays to prevent large congregations. Despite this there were violations all over the country. Most notable was the controversial Lal Masjid cleric Maulana Abdul Aziz in Islamabad who directly challenged the government by not only holding large congregations at almost every prayer but also declared brazenly that he would continue to lead the prayers. Full capacity pictures from inside Lal Masjid in Islamabad during the lockdown were shocking, though the government has taken no action so far.
Moreover, on 14 April, prominent ulemas rejected the government restrictions and declared that daily congregational prayers, including on Fridays, would held in mosques. One of the ulemas insisted that in order to get rid of the virus, the best way was to increase the attendance in mosques.
The situation was especially fraught due to the forthcoming month of Ramzan and the get-togethers for Sehri and Iftar as also for special prayers taraweeh and aitekaf. To avoid a confrontation, the President of Pakistan Dr Alvi met prominent ulemas and worked out a 20-point compromise agreement which is reportedly not being implemented. Under this all the demands of the clerics for holding daily congregational and taraweeh prayers in mosques during the month of Ramazan were accepted with certain precautionary measures for social distancing. However, the clerics declined to take any responsibility related to the enforcement of these precautionary measures.
In effect, by ignoring the safer course adopted by countries like Saudi Arabia, Iran, Turkey, Egypt and Jordan not to allow congregational prayers in mosques, Pakistan has taken a huge risk. Enforcing and monitoring social distancing norms would be an impossible task since there are tens of thousands of mosques all over the country. In such a scenario, allowing daily congregational prayers for a whole month could well facilitate the coronavirus pandemic to spread far and wide and lead to an exponential increase in infections and casualties.
Clearly, the government has buckled under the pressure of the clerics with Imran Khan unable to exercise strong leadership in a crisis. The Tableeghi Jamaat congregation in Raiwind in March had led to a spike in Covid-19 cases that provided strong evidence of what happens when social distancing is not observed during religious events. Despite this example, for the government to allow congregational prayers during Ramazan could well prove very costly for Pakistan.
Pakistan is quite likely entering a very dangerous phase. One doctor summed it up best when she told the media: “We’re likely to have a very big outbreak no matter what we do now. And we will not be equipped to handle the numbers. There will be breakdowns at many levels. Better border controls and quarantine measures should have been instituted a lot earlier, but I think the cat’s now out of the bag.”
As the experience of different countries shows, the initial belief that a few weeks of lockdown would be enough to defeat the virus was grossly misplaced. There is unlikely to be a return to business as usual for some time to come. Pakistan, like other countries, would not only need to ensure a proper lockdown but hunker down for the long haul. As of now it does not appear that it is either prepared or willing to do so.
(The writer Tilak Devasher is the author of three acclaimed books ‘Pakistan: Courting the Abyss’; ‘Pakistan: At the Helm’ and ‘Pakistan: The Balochistan Conundrum’. He is a former Special Secretary, Cabinet Secretariat, Government of India. He is currently Member, National Security Advisory Board and Consultant, Vivekananda International Foundation. The author has mentioned 26 references in the footnotes which are not being mentioned here due to short of space but the newspaper has their details.)