Questions about Pakistan’s Covid-19 control strategy

All of us have the responsibility to ask questions and hold decision-makers to account

As a Pakistani who has spent the past 16 years working on strengthening policies and systems for infectious disease control, focusing on pandemics in recent years, I am concerned at the policy-making process for Covid-19 in Pakistan. I know I am not alone, and that Pakistani public health experts share my concerns. However, I come with some good news at a time that is incredibly difficult for us all.

We need to move beyond the lockdown debate

We have spent far too long debating lockdown versus no lockdown, and it has paralysed us. Covid-19 in Pakistan can be controlled without a complete lockdown. We do not need to choose between saving lives and saving the economy.

In public health terms ‘lockdown’ has no meaning, as it does not refer to a standardised strategy. Countries have used different approaches to reducing population movement and mixing (which is what a lockdown refers to), based on what is right for their society. For example, in Wuhan, China, there were strict restrictions on residents in the entire city on leaving their homes, but in the UK people were allowed to go out for daily exercise and essential shopping. Irrespective of whether it is a rich or a poor country, public health experts know that a lockdown is not a feasible long-term strategy.

The debate about a lockdown in Pakistan has distracted us from focusing on the most important strategy that we need to implement urgently: that is to test all people suspected of having Covid-19, find their close contacts, and support those close contacts to stay away from other people (isolate) for at least 14 days. This will reduce the number of people each infected person is able to pass the virus on to, as case numbers will decrease. The test, trace, isolate (TTI) strategy – as it is known – is proven to work, and is therefore recommended by the World Health Organisation. Countries that have implemented it effectively – such as Vietnam, New Zealand and Singapore – have contained the virus with few deaths and cases. By using this approach to eliminate virus circulation in the population, countries have been able to resume business and social activities. Moving forward, people from countries that have implemented this strategy to control the virus successfully will be allowed to travel freely, while countries with poor Covid-19 control will be subject to travel restrictions.

Pakistan can control Covid-19 with existing resources

No doubt it is not simple to implement the TTI strategy, but it can be done with existing resources if the right experts’ advice is taken. We are often quick to jump to the excuse that Pakistan is too low on resources to do what is needed. That excuse is not valid in this case.

Vietnam, which has a population of 95 million, has had no deaths from Covid-19 despite having very limited resources for Covid-19 control, and despite sharing a border with China. Pakistan can learn lessons from Vietnam by focusing on: an effective communication campaign so that the population understands and supports the government strategy, actions against people who spread fake news to derail progress, and using existing community-based and business networks to support tracing of potentially infected people and their isolation. We could also prevent Covid-19 from spreading into new areas, by temporarily restricting travel from urban areas with high infection to rural areas that do not yet have the virus. This will allow us to focus our resources on current hotspots and avoid having cases in rural areas with limited healthcare facilities.

There is no reason for the strategy and evidence on which Covid-19 control decisions are being taken to remain hidden.

We must remember that although we often say we have limited resources, we can mobilise what we have, which is plenty. Public health experts like myself and numerous colleagues, are willing to provide expertise and data analysis skills for no cost. There are businesses and volunteers that are ready to support families or communities that isolate themselves to avoid infecting others. Giving up and allowing the virus to spread because we cannot afford to lock down, is a potentially disastrous approach. Some people may talk the virus not being very dangerous because of a low overall death rate, but what this means is that it is okay to let a small percentage of people die just because they happen to be elderly or living with another health condition – is this how we treat our vulnerable family and community members? In addition, we already know this virus causes long-term effects in young and healthy people who survive, so death counts hide the true impact of getting infected. While we should not let our focus on Covid-19 disrupt services for other important illnesses, allowing it to spread is killing healthcare providers and forcing us to divert limited funds for health improvement in Pakistan towards intensive care facilities.

Why have proven, effective strategies not been implemented yet?

Given that we can implement effective strategies to simultaneously save lives and the economy, the natural question is why this has not been rolled out with full force. Here all of us have the responsibility to ask questions and hold decision-makers to account. The public has a right to know who is leading Pakistan’s Covid-19 strategy at the national and provincial level.

We need to be able to hold policymakers accountable for success or failure as every one of us is impacted: children missing school, adults dying or getting sick, and businesses with reduced profits – the list goes on.

Who are the independent expert advisers to policymakers and do they cover all the necessary expertise?

We must note here that public health – which is the field that is needed here – is distinct from medicine. While medicine focuses on treating individual patients, public health focuses on systems including those for reaching out to communities, for management of logistics and for assessing the costs and benefits to the economy. You cannot solve a public health crisis without engaging public health experts who know what to do. It is as simple as that.

What evidence-based advice has been given by the expert advisers and how has this fed into the strategy?

In countries like the UK, people have demanded that expert advice be made public, and this has improved the decisions being taken by policymakers. There is no reason for the strategy and evidence on which Covid-19 control decisions are being taken to remain hidden. We should no longer accept that there is not a clear strategy, or accept being told that actions are based on ‘sophisticated models’ or ‘strong scientific evidence’ without being able to see the same information that the decision-makers have.

In this crisis, more than any health crisis before, we all have too much to lose if we are silent observers. We need to ask questions loudly and immediately.

The writer is an associate professor at the London School of Hygiene and Tropical Medicine, specialising in strengthening infectious disease control systems in lower-income countries

Questions about Pakistan’s Covid-19 control strategy