Pakistan lockdown: Sophie’s choice!

Three things are now known for certain: one, coronavirus is not a flu; two, it is a lot more dangerous than flu because it is highly contagious while nearly half the carriers are asymptomatic, and; three, without containment it will have catastrophic effects on human lives and economies.

One solution is to “flatten the curve”—i.e. contain the outbreak which will likely lengthen the duration the disease will stick around but limit the damage it leaves in its wake as governments will have more time to tackle the crisis. There is however no consensus on which containment strategy is the best. Evidently, there is a need to look at how the world is tackling it, how some containment efforts have worked and others haven’t, and what important strategies may be adopted. Is complete lockdown the right way to go?

Of course, there are merits (reduce the spread by keeping people in) and demerits (huge fiscal and administrative burden) of lockdown itself. PM Imran Khan announced a Rs150billion cash support (part of a larger relief package) for nearly 12.5 million houses—that’s 39 percent of the population but covers 4 months of cash transfer at Rs3,000 per household. BR Research calculations suggest that the average spending on food alone by the lowest 40 percent of the population is roughly Rs11,000. That’s more than Rs100 billion per month for the bottom 40 percent (read: “COVID-19 lockdown: Can we afford to feed the poor?” March 25, 2020). This, together with lockdown administrative expenditures and loss of employment and slump in business demand – may wreak an economic cost too heavy to bear.

On the other hand, without a lockdown, risks of outbreaks are huge. For a population size of Pakistan’s, barely sufficient (or efficient) healthcare service delivery system will collapse long before the crisis could rear its true ugly face. The vulnerable population is huge —39 percent of the Pakistani population today lives in multidimensional poverty. A huge share (22%) is undernourished. Assertions that Pakistanis may have stronger immune systems are not backed by evidence. Meanwhile, for every thousand people in Pakistan, there are less than 0.6 beds, and 1 physician. A combined public and private inventory shows there are about 1,700 ventilators. By yesterday, positive cases in Pakistan had crossed 1,000. True, many of these are not high-risk cases but it remains unknown how many true positive cases the country may actually have.

Let’s look at two contrasting examples to learn from, that adopted vastly different strategies to deal with the outbreak: Italy and South Korea. Italy has had a massive outbreak forcing its government to lockdown the country while South Korea has managed to flatten the curve substantially without having to lockdown. A major difference is timing. South Korea acted fast and started indiscriminate testing of people — with or without symptoms. Roadside medic tents were setup with free drive through testing. This allowed the country to quickly recognize the extent of the outbreak and contain it. The country established isolation centers and temporary hospitals similar to China and quarantined all positive cases as they came.

Mind you, Italy spends more on its healthcare as a share of GDP than South Korea does. It also has more physicians per 1,000 people. The two countries also have similar GDPs per capita. But while South Korea acted fast — it carried out nearly 7,000 tests per million people; Italy was only testing people with symptoms. South Korea’s testing was followed by a rigorous tracking of contacts and quickly quarantining them. Technology played a predominant role (something that the Pakistani administration has also managed to adopt).

Another prominent example is Singapore that has also done massive testing — 6,700 tests per million people but the country has been shielded from the crisis because only 1 percent of its total tests came out positive. Other factors such as travelling, and tourism may also have played a role here. Some have argued that Asian countries have faced similar outbreaks like this before (e.g: SARs and MERs) so they are more prepared, and their populations are culturally more isolated. Most of these populations are already used to wearing masks due to allergies and past outbreaks and are typically more cautious. That may/may not be the case.

However, there is also a clear difference in approach: indiscriminate testing versus only testing those that are displaying symptoms. The latter hides the extent to which the spread has already happened. Without knowing how far the disease has spread, any targeted containment cannot be sufficient.

Back home, so far only 30 tests per million have been conducted — compared to the 4,000-7000 tests per million done across other countries. Since Pakistan is also only testing high symptom patients, infection rate of 16 percent is significantly greater. This number represents positive cases of the total tests done which reduces as more tests are done but only if these are done before the outbreak happens (for more, look at Italy’s high infection rate despite over 4,000 tests per million. The country was simply too late. By the time it ramped up testing, the outbreak had already gotten out of hand). The longer it takes for the government to conduct tests, the greater the outbreak will be. So, not only does testing needs to be on a mass-scale, it also needs to be done faster.

The question is: does Pakistan have enough testing kits? If South Korea is mass-testing, it is because it was able to produce its own kits. Next, how can mass testing be administered? Does the country have facilities and doctors to give out those tests? Can tents be pitched and provide drive-through tests to every individual that comes in? Does the country have extraordinary level of organization and coordination required to systematically test clusters of people; and quarantine them at isolation hospitals and negative pressure rooms as they test positive? This all requires tight coordination, sheer manpower and of course, money!

Let’s throw in another country. Japan. Folks have self-congratulated the low number of positive cases in Japan but the country in fact is not testing enough and is facing a false sense of security. At 193 tests per million people, Japan is far behind other Asian peers. Without testing enough people, the country is in the dark, and cannot strategize most effectively. Pakistan is in the same boat — except Japan has more beds, more doctors, and a much stronger economy!

The learning here is simple: knowledge is power. The faster the government knows the true extent of the spread, the more likely it is to reduce its need for draconian measures such as a complete lockdown. Right now, Pakistan appears to be headed in Italy’s direction. The positive cases against tests done are too high and while it took 6 days for Italy to double the number of positive cases, Pakistan doubled them in 5. Unless it gets on South Korea’s path, a lockdown seems to be the only option. But for how long?