Explained: How Pakistan won the first battle against COVID-19

International media had written Pakistan off as a disaster waiting to happen soon as coronavirus first emerged in China. A ticking time bomb due to decades of corruption and neglect, it was doubtful Pakistan’s healthcare system could bear the shock in case the country saw exponential growth in cases.

To date, the country has seen 6,267 deaths from Covid19. Nobody really knows how Covid19 disappeared, or why the scenarios predicted miraculously never happened in Pakistan. It may take years before researchers can provide scientific basis for it, but it is certain the country has been spared much of the destruction promised. To date, the country has seen 6,267 deaths from Covid19.

An element of mystery enshrouds the response it took for Pakistan to tackle the pandemic. Brushing aside even possibility of success, commentators have presented theories ranging from ‘x’ factors to mystical elements or seasonality of the virus. Too little is yet known about the biology of coronavirus to rule anything out, but there may, however, be a few slightly more tangible explanations.

Timing of the response

For what is uncharacteristic in Pakistan, fear of the unknown virus pushed authorities to take bold decisions early. In doing so, they nailed one thing which proved effective in the long run: the timing of their response.

On March 13, as the first known case of community transmission was detected in the country, all educational institutions were closed, board examinations postponed, and international flights were cancelled, except at three airports. Role of preventative behaviours in ‘flattening the curve’ was under-appreciated at the time, but Pakistani government started laying emphasis on following a set of public health interventions it referred to as ‘SOPs’, or standard operating procedures.

Critics deemed these steps inadequate in the fight. Pakistan’s Prime Minister, Imran Khan, had ruled out national lockdown, repeatedly voicing concern for the economically vulnerable. Miscommunication from top officials, and the confusion which followed, raised inevitable questions whether Pakistan had any plan at all. Cornered into an awkward position, provincial governments decided to move forward with the only strategy which seemed to be working at the time for other countries.

No death had yet been reported in Pakistan when Sindh took the decision to hold remaining Pakistan Super League games behind closed doors. This was a big step, considering the tournament neared its end, and what it meant for the homegrown league to be played on home grounds instead of the neutral venue UAE, where Pakistan hosts cricket due to security concerns.

Punjab stuck to advice from infectious diseases experts. The province had already made the decision back in February to impose a period of - what it called - “shutdown”, when first death from local transmission occurred in the country.

Government of KPK had introduced a number of restrictions, but it was Thomas Poyo’s viral article which forced KPK's Minister of Health to up the ante regarding the Covid19 strategy. He managed to persuade higher officials in the province to take broader measures.

Against the Prime Minister’s wishes, the country of 220 million gradually began to lock down. By March 24, when there were less than 10 deaths in Pakistan, each of its province had managed to put in place somewhat-strict lockdown measures.

The efficiency displayed, in preparing for the imminent threat, was unusual for Pakistan.

State of emergency was imposed in five districts of Balochistan bordering the Covid19-battered Iran. To quarantine growing number of returning pilgrims from Iran, quarantine centres were quickly set up throughout the province, with major centres located in Quetta, Chaman and Taftan.

Province of KPK, which had only started to show glimmers of recovery from decades of being on frontline in Pakistan’s war on terror, was unarmed for this battle. The only public sector diagnostic lab in the province of 35 million, had capacity to carry out 40 investigations per day. Staff at the lone testing facility worked tirelessly to clear backlog of samples, while five different labs were set up in KP within a month. By April, the province managed to build capacity to around 1000 tests daily.

Pakistan’s Covid19 cases were concentrated in Sindh, but 40 percent of the province’s hospital beds — one bed for 1200 people —were concentrated in the city of Karachi. Authorities scrambled to set up "quarantine rooms” in each district, and 12 isolation centres were established where those testing positive were made to isolate. Within a month, the province built capacity to sample 2000 tests daily.

In Punjab, hospitalisation of confirmed Covid19 cases was made compulsory. “Punjab was the only province which required even asymptomatic cases to isolate at government facilities.” Azhar Mashwani, a representative of the Chief Minister Punjab’s, told Business Recorder. Rumours emerged the police was sent to guard homes of close contacts while they self-quarantined, and a few run-ins were reported in the media, but officials insisted policing was necessary to arrest the pandemic.

Around 30,000 beds were added to existing capacity in Punjab as its Covid19 cases reached 300. Hospitals were alerted to check suspected patients for Covid19 symptoms and refer them to isolation centres accordingly. A 1000 bed field hospital was set up in Lahore to cater to Covid19 patients in case hospitals couldn't cope. Risk of hospital infections was minimised by allowing doctors two weeks off to self-isolate after working six days, according to Mashwani.

As thousands of Pakistanis began to be repatriated from Covid19 hot spots, passengers arriving in Lahore went through a rigorous process to be able to go home. Returnees were sent to quarantine centres to isolate for two days before getting tested, then wait at the facility till results could be obtained. Those testing positive were isolated for two weeks, while those that tested negative had to wait 24 hours to take another test.

Planning and preparedness:

Quick decisions provided time to set up facilities, procure equipment and mobilise resources. That the country utilised this time effectively, is perhaps the most unbelievable aspect of it all.

In countries like Italy, Great Britain and USA, an initial period of denial, followed by refusal to act early, and wasting the time bought by lockdown, meant health systems choked fairly quickly in the crisis. Recurring issues regarding testing, shortage of PPE, overflowing hospitals, or lack of ventilators, forced many governments to their knees.

The speed with which various pieces of the puzzle of Pakistan’s Covid19 strategy started to fall into place was, in hindsight, unprecedented. Pulling a rare feat, Pakistan’s federal and provincial bodies worked in synchronisation with its military to avoid these scenarios.

The National Core Committee (NCC), chaired by PM Khan, was set up to monitor Covid19 response. National Command and Operation Centre (NCOC) was established, including various organs of state, for robust implementation of decisions made by NCC to help erect the infrastructure required to combat Covid19. “The integration with which we worked, from top all the way to the grassroots, was exceptional. The extraordinary level of focus, coordination, and ability to take decisions in one room made success possible,” said Pakistan’s Minister for Planning, Asad Umer, who chairs NCOC.

National Disaster Management Authority (NDMA) was activated, which played a pivotal role in ensuring supply of medical equipment to each hospital.With help from NCOC, number of ICUs rose from 700 to about 20,000 within a few weeks. There were less than 2,200 ventilators in the country when, despite global advance bookings, NDMA used various diplomatic channels to secure 1000 more. Amid drastic worldwide shortage, Pakistan built sufficient PPE stock by April.

By end of April, NDMA had worked with the government to more than double the number of Covid19 testing facilities.

Demography favoured Pakistan

Experts believe it’s younger population is the principle reason behind the relatively low severity of Covid19 experienced in Pakistan. It is known risk of severe infection increases with age, but 95 percent of Pakistani people are under 65 years old.

“Pakistan is probably not underreporting data. Countries cannot hide deaths and morbidity. The huge population of young people, most of whom are asymptomatic and may not bother getting tested, is the reason behind our low case numbers.” Dr Shazia Fazal, Executive Director at Mid-City Hospital Lahore, told Business Recorder.

Contact Tracing

Officials from different provinces confirmed contact tracing was carried out rigorously to delay community spread as much as possible. An app used by Pakistan’s intelligence agencies to track terrorists was quickly repurposed for surveillance of Covid19 suspects. Automated notifications were sent when someone tested positive or had been in contact with an infected individual. Once someone was identified via confirmed positive test, local authorities visited them and their close contacts. Isolation and home-quarantine measures were evaluated, and their testing was fast-tracked.

By April, the surveillance system had tracked 175,000 people, while response teams worked at district levels to collect samples for testing.

As is usual in epidemics, the tipping point came when community spread could no longer be contained; this is when epidemiologists recommend redeploying resources required for contact tracing towards efforts with broader reach. “By May, as cases ballooned, there were signs in Punjab that contact tracing was not scaling. We prioritised directing efforts towards strengthening the healthcare system,” Mashwani said, speaking of Punjab. Zain Raza, his counterpart in KP, confirmed the same.

“In Islamabad, we have diligently carried out contact tracing to best of our abilities. Clusters of around 7,000 families have been put under quarantine in the city,” Dr Zaeem Zia, District Health Officer for Islamabad, told Business Recorder.

In Pakistan, there is skepticism about any efforts at contact tracing, but results have bore fruit. Few super-spreading events resulting from community transmission have remained undetected in the country.

Containment vs mitigation

In India, a severely mismanaged lockdown triggered a mass exodus of migrant workers, causing the virus to spread in different parts of the country very early. In Pakistan, a state of alert displayed, in the month following the first death, is likely to have prolonged what is known in epidemiology as the ‘containment phase’.

Used at start of an outbreak, containment involves actively tracking and trying to stop the disease from spreading. Every day is critical in a pandemic with exponential growth; the longer the pause on spread, the more time governments have to mobilise, and fortify healthcare systems.

The downside to containment, however, is that once it is lifted cases surge again. Pakistan seemed prepared for this, too. The Pakistani government had highlighted the need to follow SOPs from the start, and its people were smooth in transitioning to the ‘mitigate’ phase once restrictions began to ease. Mitigation focuses on ‘flattening the curve’ by slowing the speed of the virus— rather than trying to eliminate it.

As the rate at which new cases appear begins to decrease, demand in peak healthcare reduces, allowing health workers time to attentively care for high-risk patients.

Riding the peak

“People assume it never got bad,” Mashwani said. “In Punjab, there was a period after Eid where it was felt the healthcare system will collapse. It stretched to capacity, there was no room available in a few hospitals. But in the end we were able to handle it.”

There were 27,000 cases, when on May 9, Pakistan lifted lockdown in time for Eid break. Four weeks later, an additional 70,000 cases were reported in the country. At its peak, Pakistan recorded 153 deaths from Covid19 on a single day.

Pakistani hospitals were able to soldier through, functioning within manageable levels at the pace with which patients required treatment at the height of crisis. “Our doctors tried to learn from the experience of countries affected before us during the pandemic, and we succeeded for it very well.” Dr shazia stated.

Where Pakistan’s weak public healthcare system lagged, gaps in provision of service were filled by the private sector. “Without private hospitals stepping in to aid the government in the time of need, Pakistan could not have dealt with the peak. We managed due to strict guidelines provided by government health authorities,” Dr Shazia added.

Testing Strategy

Pakistan has conducted a total of 2,535,778 Covid19 tests to date.

Khan’s government has been accused of artificially deflating the pandemic by keeping the testing figures low. Actual toll from Covid19 is likely to be much higher, but Pakistan hasn't really seen it’s hospitals overflowing past capacity.

Having realised early on it didn't have the resources to try and aggressively look for new cases, priority was given towards providing tests to symptomatic individuals, international travellers, and those identified as close contacts.

Similar to Pakistan, countries like Greece, Nigeria and Cuba also discarded mass testing as a strategy. Despite testing less than 1 percent of their populations, the countries received international praise for handling their Covid19 crises, by keeping death tolls low, while sustaining their health systems.

On the other hand, Pakistan has garnered constant criticism for not testing enough, although statistics show it has conducted more Covid19 tests than Greece, Nigeria and Cuba. Pakistan’s GDP per capita, however, is less than each.

By early as April, Pakistan had initiated targeted testing in areas with high transmission, in a strategy it referred to as ‘smart sampling.’ This was the advent of the ‘smart’ approach - crown jewel in Pakistan’s coronavirus response.

Smart Lockdown

Khan maintained a stubborn stance to find innovate solutions tailored to Pakistan’s reality. Under the premier’s guidance, NCOC began consultations in April with researchers from Pakistan Institute of Development Economics, Council of Economic Research in Pakistan, and Lahore University of Management Sciences, to devise ‘smart’ Covid19 strategies.

Rather than opt for blanket lockdown, ‘smart lockdown was devised to identify locations with risk of increased infection. Shutting down only selective areas paves way for lifting restrictions in other places where social distancing is practiced.

Smart lockdown strategy prioritises protecting the vulnerable. “It is necessary to realise how important it is to save our elders and those who are sick. The aim behind smart lockdown is to protect them,” PM Khan stated in a session of the National Assembly. Epidemiologists have also recommended the best approach to reducing morbidity and mortality is to protect the vulnerable during the early stages.

By May, more than 500 smart lockdowns were operational in Pakistan. By end of June, these were extended to 20 cities across the country.

The results showed in merely weeks. By mid-July, the number of Covid19 cases reported daily was slashed by more than 50 percent, while there was a 28 percent reduction in critical cases.

Past experiences

Like many countries which have flattened the curve, Pakistan drew on its past experiences with struggling to manage frequent, smaller outbreaks. The country had advantage of having built practice over years from dealing with diseases which remain endemic in the country, such as malaria, dengue and polio. Vast infrastructure, developed to track these diseases in every district of Pakistan, was modified overnight to aid in the crisis.

The National Emergency Operations Centre (NEOC) for Polio was upgraded, diverting 10,000 health facilities and over 25,000 workers towards Covid19 surveillance. Before even the first death was reported in March, polio teams had given Covid19 sensitivity training to over 6,200 health workers.

“We leant heavily on the health systems set up previously by the NEOC for polio. All data collation and reporting is done through their polio surveillance network.” Asad Umer commented.

Ghabrana Nahin Hai

The Prime Minister appeared in frequent media briefings, where he was comfortable in allowing relevant officials to assume centre stage, in keeping the nation informed. Drs Zafar Mirza, Faisal Sultan, and Moeed Yusuf, became key figures in the Covid19 discourse in Pakistan.

The cash strapped country launched an economic relief package worth $8 billion, and a successful cash transfer scheme had distributed monetary grants to more than 5 million people by May. By working night and day to ensure demand for essentials was met, mass hysteria, hoarding and stockpiling, seen in other countries, were completely averted.

“Stimulus reaching people meant they stayed indoors, trusting that they will be cared for. It prevented them leaving their homes ,in desperation to look for food or medicine, which was the exact situation we were trying not to create,” said Zain Raza, Covid19 representative to KP’s Ministry of Health and Finance.

Prime Minister Imran Khan’s reluctance to impose national lockdown was unwavering. “We remained open to learning from mistakes. We debated endlessly at NCOC on the right strategies, but we were not swayed in our decisions by any pressure.” Asad Umer said. “We learnt from other countries, but knew we had to work within our particular circumstances,” Asad Umer said.

Amid the pressure that built around him, Khan refused to bow down, repeatedly expressing fear that daily wagers, and those employed by the country’s informal economy, would not be able to bear the impact of lockdown.

From day one, the Prime Minister provided a vision, but it took a while for people to realise he had been right about lockdown all along. Even in countries where the strategy worked, lockdown was never the goal itself, but a means to get there. Khan displayed leadership in stepping back by not overriding provincial authority, but he underestimates the role his provincial governments played - by risking his wrath and initially locking down for those few weeks - in seizing valuable moments to further strategise as time was slipping by.

Epidemiologists had always suggested the most effective interventions against Covid19 were changes in personal behaviours (wearing masks, hand washing, maintaining distance, etc). However, the media mocked the Pakistani leader, drawing parallels between him and Brazil’s Bolsanaro, for his pragmatism about adapting to ‘living with coronavirus’, or telling people they need not to panic (ghabrana nahin hai).

“Imran Khan never said there was nothing to worry.” Asad Umer clarified. “He said if you are sensible and take precaution, supported by actions of the government, you will be okay.”

The same views were later echoed by WHO Chief, Dr Tedros Adhanom, when he said “we must learn to live with the virus.”

“Khan struck the right balance between reminding the need for caution, but at the same time convincing people not to panic, that government is taking the steps to protect both lives and livelihoods.” Asad Umer commented, “People bought into that confidence. Thats why the nation felt the ease to go along with what he asked them to do.”

The ‘x’ factor

Some experts believe a degree of cross immunity, built from exposure to other common coronaviruses, is the reason developing nations fared better against Covid19. However, examples of varying epidemic trajectories in the same geographic region — where one country is lifting restrictions, while another is facing extreme devastation, as is seen in Latin America, Africa, and even between India and Pakistan — hint that if there is some prior immunity, it may only be playing a small role in fighting the virus.

What is fact, however, is that the course of a country’s epidemic is tied to the health interventions introduced by governments. Thus, every policy formed to counter the threat played a direct impact on how a country managed to flatten it’s Covid19 curves. By suggesting involvement of unknown factors, observers have overlooked giving Pakistani authorities the credit they rightfully deserve in pulling off the unexpected. “What helped was we had absolute clarity we needed to open up the society and economy for people to survive, while also putting in measures for disease curtailment,” Asad Umer recalled. “In the end, the world ended up looking to Pakistan for suggestions,” he added.