Explained: ‘Mysterious’ decline in Pakistan’s Covid-19 cases

From a peak of over 6,000 daily Covid-19 cases in mid-June to just 300-odd daily fresh cases in September, Pakistan has witnessed a dramatic decline in the numbers over the last few weeks. It has reported 297,512 cases so far, which includes 6,335 deaths and 282,268 recoveries. Currently, there are just 8,909 active cases in the country.

With a population of 220 million, meagre health resources, crowded cities, economy in shambles, it was projected that Pakistan would see at least close to 80,000 deaths by August. But surprisingly, the number of infections has plummeted in recent weeks, with Covid-19 deaths hovering in the single digits each day. This has left health experts baffled as they are trying to look for reasons behind the “success” even as neighbours like India continue to witness a surge in numbers.

Pakistanis have proposed numerous hypotheses for their country’s seeming ability to weather the pandemic, crediting everything from the young population and the hot and humid climate to unproven claims of natural immunity. So, did Pakistan really manage to flatten the curve or is there more to it than meets the eye?

Age demographics a factor?

Pakistan’s median age is only 22 and the coronavirus is known to disproportionately impact older people with prior health complications, which can be one of the reasons that the South Asian nation has been able to control the pandemic.In comparison, Italy, with a median age of 46.5, has recorded more than 35,000 deaths, while Pakistan’s official toll is about 6,300. A flattening curve is all the more curious considering how the coronavirus has hit India, which with a median age of 26 and crowded cities has a somewhat similar demographic.

During the Covid-19 pandemic, the worst-hit countries have an average age of 35-45, so Pakistan median age being 22 could be a factor.

Is low testing behind low numbers?

Experts have said that testing and tracing have been the key factors in Pakistan. The government said the virus outbreak was controlled in the country due to “concrete measures” taken by the government through its trace, test and quarantine (TTQ) strategy. In the last week of August, Pakistan’s positive test rate – a key indicator as to whether there is adequate testing – was 2.09 per cent, well within the World Health Organization’s 5 per cent threshold for indicating that a country’s outbreak is presently under control, according to a report in Al-Jazeera. However, observers say that with only limited testing the true number of infections is likely considerably higher.

Compared to neighbouring India, Pakistan falls way behind when it comes to testing its population. The above graph shows that while India has hit a record high of over 1 million tests per day, Pakistan has been averaging around 20,000+ daily tests since June. Further, according to data from worldometers.info, India has tested over 4.6 crore people for Covid-19 so far with an average of 33,767 tests per million population while Pakistan has tested just over 27 lakh people with an average of 12,216 tests per million population. Speaking in terms of percentage, India has tested nearly 3.3% of its population and Pakistan has tested just over 1.2% of its total people.

With testing being one of the main reasons for higher numbers, the data indicates why we may not have a true picture of the pandemic’s spread in Pakistan.

Cases under-reported?

A seroprevalence study conducted in July in collaboration with WHO estimated that 11 per cent of Pakistanis have developed Covid-19 antibodies while 89 percent remain at risk. Similar sero studies in India have also indicated that the number of people infected by the disease could be much higher than what has been reported. A report on Deutsche Welle quoted a government official from Punjab province who said that he had direct orders from his superior to omit numbers by almost half. This month he reported 34 new cases, instead of 63.This is indicative of “willful misreporting” at the district level and raises concerns regarding the accuracy of the official figures. Misreporting, coupled with a decrease in testing, greatly skews the recorded prevalence of cases in the country, the report quoted experts as saying.

Fear of social stigma

One theory surrounding the low numbers suggests social stigma as a strong factor where people fear coming out openly about the virus which has led to many people not getting tested unless it is an extreme case. According to a report in Deutsche Welle, “Given the total number of infections in the country, people are now more aware of Covid-19 symptoms and are not coming to hospitals unless they become severely ill.”DW quoted, Hina Shah [name changed], a doctor at PAF Hospital in Islamabad, saying, “Whole affected families are not coming to hospitals, there is some stigma attached but also many people choose to quarantine themselves,” she added, underlining that the decline in numbers is also due to people opting not to go to hospitals and get tested. Experts also said that people are scared of going to hospitals or getting tested for fear of being ostracized in case of infection. While stigma around the disease exists in India as well, the central as well as state governments have taken several pro-active steps – from public awareness campaigns to free testing in certain rural areas – to tackle the challenge.Another important factor, as observers have suggested, could be the almost negligent trend of pub culture in Pakistan, compared to the Western nations.

Fatality rate

Even though its overall case count is less, Pakistan’s Covid-19 mortality rate stands at 2.1 per cent which is higher than that of India’s 1.8 per cent.In fact, India has seen a gradual decline in its fatality rate over the last few weeks while Pakistan’s fatality rate seems to have remained consistently above 2 per cent for nearly two months.

Pakistan has, so far, reported 6,335 deaths from the virus while India has reported more than 64,000 deaths – the third-highest globally after the United States and Brazil.

Smart lockdowns did the trick?

The government of Prime Minister Imran Khan has been quick to bask in the progress of the Covid situation, crediting itself with “smart” lockdown policies and other measures. Khan’s government has opted for “smart lockdowns” as a way to curb the virus’ spread while ensuring economic activity continues unperturbed. Smart lockdown involves shutting down smaller regions in response to new outbreaks as opposed to bringing their entire country to a halt.Planning minister Asad Umar said that the smart lockdown strategy had been helpful in reducing the spread of the infection. He said now the policy was to move towards “micro smart lockdowns”, which aimed to put under lock down only a small group of houses.

Hospitals see less Covid patients

While experts are not able to provide any particular reason for decline, anecdotal evidence from hospitals across Pakistan supports the downward trend. While healthcare facilities were initially swamped, doctors across Pakistan told AFP they are now no longer seeing a coronavirus-related rush on emergency services. “Regardless of the reasons, the good thing is the first wave of the virus is almost over in Pakistan,” said Khizer Hayat, a doctor at Nishtar hospital in the central city of Multan. “The situation is now under control and the number of coronavirus cases is dropping, the wards are emptying. It’s hard to know why,” he added.

Possibility of second wave?

Since recording its first case in late February and then imposing restrictions, Pakistani authorities have now lifted most of the country’s remaining coronavirus restrictions after new cases dropped for several weeks. Restaurants and parks have reopened while people have flocked to theatres, malls, and crowded back onto public transport. Schools and universities are set to reopen later in September.Masks have become an increasingly rare sight, spurring warnings from experts for the public to remain vigilant over fears of a second wave. “People think we have defeated Covid-19 but my belief is that the chances of the second wave are still there,” warned Hassan Waseem, a microbiologist based in Pakistan. However, other doctors suspect the country has experienced the peak of the pandemic. “I would reluctantly say that there won’t be a second wave in Pakistan. Most urban centres in Pakistan like Lahore and Karachi have already seen the worst when it comes to coronavirus,” said Waheed Uz Zaman Tariq, head of the department of virology and infectious diseases at Chughtai Lab.

Success yes, but fight far from over

Even when the country has largely succeeded in controlling the pandemic, the fight is far from over. Several countries, including New Zealand, Australia and Veitnam, which declared themselves coronavirus-free, have witnessed new infections. Health experts and the government authorities have been continuously warning against any kind of laxity regarding the coronavirus and have advised people to take measures including social distancing and wearing masks, among others. The WHO has also maintained that the virus is not over yet and that it will go on for a long time.

With the country reopening again, the possibility of another surge cannot be ruled out yet.