Has Pakistan weathered the Covid-19 storm?

During the height of the coronavirus pandemic in Pakistan, particularly in June, when dire predictions were being made about millions of fatalities in the country, many reporters and researchers seemed to have gotten it all wrong. There were accusations of the government covering up infection rates, of un-reported spikes in deaths and shrill demands for a total lockdown. One researcher, however, who was actually working with the government in a public health advisory role, with training in infectious diseases, Dr Adnan Khan, seemed to have gotten it right from the start.

I noticed his updates on social media and week after week he was proven correct. Unlike others who were basing their views on second hand sources and reports coming in from panicked health workers, he had access to the field level data coming in from around 450 hospitals and labs across the country. “You take a look at the data and you get a picture” is how he described his work with Dr Faisal Sultan, who was recently appointed the Special Assistant to the PM on Health. Dr Adnan, who is based in Islamabad, had already been working on other programmes like polio, HIV and family planning so had plenty of experience in working with the government.

Finally, with coronavirus infections dwindling down to 200-300 a day, I decided to interview Dr Adnan to find out what were the “multi-factorial” reasons for the decline of the virus in Pakistan. “The government actually did a good job. It was a data driven operation,” he explained. Data software helped to analyse the data sent in by the field responders. All this was done under the umbrella of the National Command and Control Centre (NCOC), which was set up in March to “synergise” a unified national effort against COVID 19. All the data from the four provinces and territories was sent to the NCOC who would come up with recommendations for the National Coordination Committee headed by the PM who would then make the relevant decisions.

“Around 12 or 13 entities including the Army and National Institute of Health and even the polio progamme worked under this umbrella. All this cooperation made the job easier”. Dr Adnan pointed out that the initial hiccups such as the Punjab government forcibly taking coronavirus positive patients to quarantine centers (which scared people off from testing) and infighting with the Sindh government were eventually overcome. “Sharing data proved to be mutually beneficial. They soon recognised that the NCOC would benefit everyone”.

There were three modeling groups within the NCOC and Dr Adnan said that Tania Aidrus’ Digital Pakistan group made a major contribution. “Tania would sit in on all the data meetings and I think 20-30% of the response was from the digital platform”. Another contributor was Dr Bhutta from Toronto, a former Aga Khan Hospital health official whose team contributed via telephone. The third group was from the Army itself who lent their data analysts. It was also the Army who actually coordinated and helped implement all the lockdowns.

“We would hold meetings on a daily basis and sometimes sit until 10 or 11 pm sharing information and discussing what to do and what to say to the public”. He admitted that the government’s messaging to the public was mis-coordinated and that has received a lot of criticism in the media. “We should have had better central coordination on the messaging of the data,” he said.

At any rate, action counted more than words and today he says the trend is that the virus is in decline with just around 200 cases recorded yesterday across the country. “I hope by September 15 we hit zero cases. If our cases finish off then the second wave, if there is any, will be mild”. His only slight worry at the moment is the opening of schools on September 15^th. “Maybe this is good enough. But if there are still 20 or 25 cases recorded by September 10^th then perhaps we should postpone the opening of schools by two weeks just to be sure”.

In his view, we may be close to herd immunity in Pakistan. “You don’t need 50-70% of the country to be infected with the virus. It was never a big deal in our rural areas – the problem is in the cities. We found that in the cities one third or 38% got infected after exposure to the virus”. He explained that people meet the same people on a regular basis. This group is their social network. Most acquaintances have similar networks. A typical urban working person’s network has around 30-35 people (it is smaller in Pakistan due limited economic activity and exposures such as subway or bus travel). Once someone is infected, everyone in their network is at risk.

As soon as people’s social networks became saturated meaning that all those in their network have been infected or avoided the infection, the infection finishes in these networks. Because most acquaintances have shared networks, the spread of infection remains limited to a small group of people. As for the rest, the two-third who were not infected but exposed to the virus (and did not get sick), it is unclear if they developed immunity.

“According to the ongoing study by the Pakistan NIH, around 5 to 15% have developed anti-bodies in cities. If you multiply that by 3 (to account for the one third of all exposure that became infected) that means 50% have been exposed to the virus. So we are getting there, to the point of herd immunity”. He said a second wave (triggered by infections coming from travellers) would be unlikely as there would be few left to infect due to the “network effect”. Plus Pakistan is not exactly a tourist destination and our limited economic activity means less investors and visitors, which has proved to be a blessing in disguise.

Pakistan’s cities also have less density than Indian cities. Our biggest city Karachi is a blip compared to Mumbai. There are “areas in Mumbai with density of over one million per square km. Pakistan’s cities cannot boast that,” explained Dr Adnan. The coronavirus spreads quickly in dense urban areas. He said India has at least 5 cities bigger than Karachi.

He pointed out that the theory that the virus has mutated and somehow become weaker in Pakistan doesn’t hold true. “There is no evidence for that”. But what could be true is that we have much greater exposure to viruses as babies growing up in the Subcontinent (which explains the low death rates in the region). “We are exposed to heavy duty infections so we develop immunity. COVID immunity is through a mechanism called T Cells which provide us with non specific immunity and protect us”. However, this is still speculation although we have some studies showing that the BCG vaccine (mandatory for TB in Pakistan) could have played a role in our stronger immunity.

In the end, he said, we can certainly be proud of our coordinated response in controlling the pandemic and the smart lockdowns certainly helped to prevent the virus from spreading. Unfortunately, the NCOC will soon be disbanded according to Dr Adnan. The data analysts will go back to their regular jobs as the pandemic winds down in Pakistan. “You have to give credit where credit is due. The NCOC did a good job in making sense of the data and coordinating different actors”

Could there be a role for a centralised unit like the NCOC run by civilians in the near future? What about the climate challenges such as floods and droughts? “Yes, we do need a unit that uses data to make good decisions. This data unit can certainly be applied to other programmes that are much needed in this country like family planning, HIV, immunisation or even climate change and water conservation”.