Why Pakistan Covid-19 numbers are not real

Recently I was asked by a senior government official as to why I said Punjab was not telling the truth about its Covid-19 cases. “This is a very serious allegation,” he told me, and “what proof do you have for this statement?” In the era of social media and rantings on our TV screens, he was right to see where I stand on my analysis.

For over a decade, my job has been to look at disease numbers, systems which generate these numbers, identify their strengths and weaknesses to ensure they could pick on a new outbreak quickly. If we identify outbreaks quickly and contain them, only then can we avoid epidemics. Globally these systems were flattering before Covid-19 and last year multiple epidemiologists and public health experts including myself raised serious questions about their capacities to quickly detect and respond to outbreaks.

It’s not uncommon in Pakistan that official records may be very different from the actual situation. During a major measles outbreak our teams went to villages in remote areas. There was zero vaccination while official records showed 100% vaccination coverage. Polio was no different and we were surprised many years back when we identified key gaps in the Lahore district when everyone was presenting a rosy picture. But finding inconsistencies in official numbers is not received well. Even though I was a US-CDC resident adviser of Government of Pakistan’s Field Epidemiology and Laboratory Training Program, invitations for independent assessments were often cancelled at the last moment when government officials became worried about the truth surfacing.

Reality is something we don’t want to face. It’s natural to avoid knowing about something which may be bad. My previous Op-ed on these pages emphasised how this attitude may prove fatal for whole populations. But when administrative officers and political leaders start making public health decisions they don’t want big numbers. Optics and narratives are more important than controlling an outbreak.

Punjab is the largest province with more than 50% of Pakistan’s population. Islamabad with two million residents was reporting an average of 80% of Punjab’s numbers. Some could make a case that Islamabad is having an outbreak but no city in Punjab, thanks to good public health measures in the province. However, Islamabad is part of the twin cities and how many cases have been reported by Rawalpindi? They are always a lot fewer than Islamabad. One could say that Rawalpindi does not have an outbreak and only Islamabad does. That does not make sense as viruses don’t stop at Faizabad police checkpost. We could easily calculate the difference of daily case rates of both cities and make broad estimates of Punjab’s under-reporting. Another glaring sign came a few weeks back when Punjab deaths started rising but its case numbers were not increasing. Death is a late indicator and only rises nearly 3-4 weeks after the increase in cases.

But let’s not single out just Punjab: how good is our national data? The purpose of any disease surveillance system is to understand the real spread of a disease. Only then we could make reasonable estimates and effective decision-making. The daily dumping of laboratory data is not the health intelligence required. To ensure a good quality surveillance system we need to stop being afraid of numbers, and let epidemiologists do their job. In the US, where pandemic response has been a failure, the President-elect has promised a new strategy starting with following science and letting public health officials make decisions and communicate to the public. We need to avoid costly mistakes of other countries and refocus on public health.

Published in The Express Tribune, November 11^th, 2020.

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