Covid-19: bad data, bad decisions

“The art of epidemiological thinking is to draw conclusion from imperfect data” (George W Comstock). As an epidemiologist we are used to working with imperfect data. However, there is difference between imperfect data and completely wrong information. Many a time, I have been told that some information is better than nothing. Yes but “something” should be real, based on facts and not false information. Wars have been lost when leaders falsely assessed their opponents’ capabilities. We are also in a war and we can’t win it based on faulty intelligence (aka health intelligence).

How are wars fought? The best are recruited and provided required resources for intelligence gathering. These people have direct access to the final decision-makers and have the authority for a quick response if needed. There is one overreaching strategy, but local commanders have the freedom to improvise based on their local situations. When a rigid central dictation of command is stressed ignorant of the local situation even the brave soldiers lose battles. Read any Pakistani military book on 1971 and you will find many instances when the Eastern Command was telling soldiers not to move to the second line of defences unless they have two-third causalities. Once they had that, they were not in a position to move anyway. The 1971 war also tells us how important national unity in the time of crisis is.

Fighting a pandemic is no different. This is an evolving virus and our strategies need to evolve with it. The whole of Pakistan will not have one pandemic but could have many outbreaks in different cities. To make effective use of our resources we need our best people to get the best intelligence against the virus. That is disease surveillance which, unfortunately, does not exist in Pakistan. The daily numbers of how many tested and how many are positive are not a replacement of a surveillance system. These numbers are just a dumping ground of testing and hospital data available.

No surveillance system could pick all cases. The most expensive disease surveillance of polio only picks one out of 1,000s of community infections as others may have mild or no symptoms. But we could work with these numbers to identify the spread in the community. We have complimentary methods to refine this data. Unfortunately, for quick answers our decision-makers, instead of focusing on a real system, are patronising overnight setups of ‘projection modelling’ and ‘prevalence surveys’. Many of these are managed by highly respectable professionals but they are not from the field and seem inexperienced in this.

The Lahore prevalence study of Covid-19 is another example of where the Department of Health, instead of fixing its surveillance system, went out for quick answers. The results of any prevalence study are based on how the sample size and samples were selected. If not done properly, the results are worthless. Looking at the version available, I am at a loss at the resources spent on this during this critical time. And even if it gave a reliable answer, what are the decision-makers expected to do with this information? What are the interventions which will be different at 5% or 10%?

Some years ago, I was sitting in an office of a health secretary of a province who later became the top bureaucrat of the country. The purpose of my visit was to bring his attention to a disease surveillance system. As soon as I started conveying the subject I was there to talk about, he told me that there is no need as he knows everything about surveillance systems. He had no public health or even prior health experience. Maybe it’s time to know what we are not expert at!

Published in The Express Tribune, June 7^th, 2020.

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