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August 18, 2020

Need for evidence

Opinion

August 18, 2020

Official figures suggest that the pandemic has abated in Pakistan. This is welcome news but we need to be sure. It would be unfortunate either if the verdict is wrong or if real gains are undone through premature relaxation.

I have some misgivings based on observations since the beginning of the epidemic. At the outset, I noted the remarkably casual attitude of individuals implementing measures to control the disease with many not following SOPs themselves.

I then tracked the case of a neighbour who tested positive for Covid-19 in a house with eight other residents. No one from the local health authorities called for contact tracing. A few days later, the person died in a hospital. Still, no one in the house was traced and tested.

I encountered families who let symptomatic elders die at home rather than visit a hospital or be tested, preferring a ‘proper’ burial to a few extra years of life and the risk of being ostracised by neighbours. Such behaviour could yield significant under-reporting of Covid-19 infections and deaths. Empty hospital beds, confirmed by many doctors, are not sufficient proof the pandemic has abated.

All along, I hardly saw real social distancing or effective use of masks. Many local markets remained busy, with people finding ways to work around restrictions. This was particularly widespread during the extended Eidul Fitr break when both shopping and travel returned to near-normal.

The most striking event was ten of the 25 members of the national cricket team testing positive before leaving for England. These were young men in their prime, athletically fit and well-nourished which suggested possible high prevalence of infection in the young. True, all of them were asymptomatic but they remained potential virus carriers. With that order of prevalence in the young and fit, what could one say about older people especially those with comorbidities?

The fact is that not much can be said without the benefit of testing, and if testing is reduced the number of confirmed infections would fall. Further, if people avoid testing and hospitals out of choice or fear, recorded deaths would decline. In addition, the positivity statistic might be distorted by increasing numbers of healthy people being tested to meet requirements for air travel.

These observations suggest that there are justified grounds for caution — independent confirmatory evidence is needed. Such evidence is not hard to furnish; one can count the dead and compare the numbers with previous years.

Many countries are now releasing such data on excess deaths to demonstrate progress in controlling the epidemic. In Spain, for example, at the height of the epidemic, fatalities were 155 percent more than the corresponding week in 2019. By the middle of May, excess deaths were down to zero, confirming control of the epidemic for the moment.

No such data has been released in Pakistan but what little has become available corroborates the phenomenon of excess deaths. A BBC report dated July 5 contained comparative data for June 2020 and June 2019 on confirmed burials in selected graveyards under municipal jurisdictions in Lahore and Karachi.

The burials in June 2020 were between 50 percent and 181 percent higher than those in June 2019. The number of burials attributed to Covid-19 ranged between 10 and and 40 percent of the excess deaths, the rest remaining unexplained.

This suggests either that Covid-19 deaths are being significantly under-reported or that non-Covid deaths have increased greatly above average because of impaired medical access, patients staying away from hospitals, or being unable to afford medications and treatment. The actual situation is probably worse because one would expect the lockdown to reduce deaths below the norm due to fewer traffic accidents and reduced air pollution.

Release of comparable data for July would answer many questions on how the epidemic is trending. If excess deaths in the same graveyards in July are well below those for June, it would be independent confirmation of a decline in the epidemic’s intensity.

If the intensity has actually declined, there could be a number of explanations that can only be confirmed later. Deaths could have remained relatively low because of the minimal number of infections imported from abroad given Pakistan’s pariah status as a tourist destination, or because of the very youthful age distribution of the population, or lower than anticipated infectivity as suggested by a very recent paper in the Quarterly Journal of Medicine (‘Secondary Attack Rate of Covid-19 in household contacts: Systematic review,’ 29 July, 2020). The last hypothesis can be validated via a follow-up survey of households reporting Covid-19 deaths. My check on the household of the neighbour mentioned earlier revealed no other person with symptoms after a month.

It would indeed be ironic if lax implementation of disease control measures has hastened herd immunity, something suggested by the experience of the cricket team. This outcome can also be easily confirmed by a well-designed protocol of randomised serological testing.

The death rate in many developed countries has fallen because the most vulnerable, especially the very old with comorbidities resident in crowded institutional homes, succumbed early in large numbers leaving behind those with better immunity. This is akin to a forest fire rapidly consuming the dry tinder before being slowed down by the remaining healthy trees. But this explanation does not apply to Pakistan where the total number of reported deaths has been relatively small.

In the absence of independent confirmatory evidence, it is not clear whether the virus has been really controlled or if there is a dangerous sense of complacency that would give it a nasty second life. It is possible to provide robust evidence to ease doubts.

Hopeful pronouncements mixed with dire warnings are a poor substitute for convincing evidence. Everyone would benefit from an end to the uncertainty and fear that are preventing a graduated resumption of activities to enable the most badly affected to restore their livelihoods.

The writer was dean of the School of Humanities and Social Sciences at LUMS.