In the ferocious battle against Covid-19, Pakistan finally has the upper hand. The last four weeks have witnessed a clear trend: cases are down, deaths are down and fear is down.

So what really happened? Here’s the story of what we know, and what we do not.

“One day in the first week of June it seemed the entire system had lost control,” says Asad Umar, the federal planning minister who heads the National Command and Operations Centre (NCOC) mandated to lead the fight against the virus. He was referring to the huge spike in positive cases in the post-Eidul Fitr weeks. This surge was caused by the opening of bazaars just prior to Eid across the country. “This was not an NCOC decision,” Umar maintains.

Read: Pakistan’s virus curve is bending but experts say it’s too early to declare victory

According to NCOC officials, Covid-19 may have peaked in Pakistan between June 15 and June 20. Statistics paint a vivid picture. At this peak, the positivity rate was hovering around 23 per cent. This means that for every hundred people tested, 23 were positive. This week the rate is 7pc. There are other data that show mid-June as the worst point since the first patient was diagnosed on Feb 26.

On June 20 — which is considered the maximum occupancy day in hospitals across the country — the number of patients on Low Flow oxygen was 1,749 and on High Flow oxygen 1,217. (This definition was created to get a sense of those less sick and those more so. Low Flow is up to 5 litres of oxygen per minute. High Flow is from 5 to 15 litres.) Compare this with the data a month later on July 21: patients on Low Flow oxygen were 458, on High Flow oxygen 762.

Here’s another data comparison to show how much the situation has improved since the mid-June peak: On June 20, patients on ventilator beds were 549. On July 21, the figure had come down to 261.

Fatality rate

The key data of course is the death rate. As per official NCOC figures, the average death rate per day from Covid-19 for the period June 17-25 was 118. In the current week, the average is 46 deaths per day.

“This was the primary data metrics (about) what was happening in hospitals,” says Umar. “By the end of June we started getting evidence that disease spread was getting controlled.”

Also read: Govt probing causes of decline in Covid-19 deaths

Even the critical figure of R0 (R-Naught) tells a heartening story. R0 is the number that indicates how contagious a disease is and how fast it spreads from person to person. If R-Naught is 1, it means every infected person will infect one more person. If it is more than 1, it suggests the disease is spreading. Conversely, if R0 is less than 1, it means one infected person is infecting less than one person which implies that the spread of the virus is shrinking.

Just before Eid in May, R0 in Pakistan was 1.5. Today it stands at 0.74.

Too good to be true? Many people are sceptical of official data. One of the most frequently asked questions is why the rate of testing per day has gone down.

Rate of testing

There can be a legitimate debate on this but at least one argument finds traction: the positivity rate does not have a direct correlation with the number of tests conducted. What does this mean? Simply put, positivity rate is a proportion of the people infected with the virus among the total number tested, and therefore lower testing could end up producing a higher positivity ratio while a higher number of tests could mean a lower ratio.

Also read: Testing not the only way to gauge decline in cases, says Zafar

Hospital data is also hard to fudge. Anecdotal evidence supports data that the load on medical facilities has reduced considerably since the last week of June. Could then the death rate be under-reported?

In recent weeks some media reports have given data comparison of burials in some large graveyards. This data has compared the registered number of burials in a particular month for the last two to three years. The results have shown a spike this year. This could very well mean that many citizens may have opted not to report the cause of death of a family member due to Covid-19 for various reasons, including the social stigma attached to the virus.

Senior officials in Islamabad admit this could be the case. But would the unreported deaths increase the reported rate by a huge margin? Even if the actual death rate were double the reported one, it would still be far less than the projections that spoke of multiple thousands of deaths per day.

So what did we do right?

This is where the debate veers off into different tangents. Pakistan got off to a rocky start. January and February were wasted in denial and March slipped by in confusion. The twin debacles at Taftan and Raiwind sparked a rapid spread of Covid-19 and forced the governments into action. However, Prime Minister Imran Khan’s vacillation in March and April ensured a diluted response from both the official machinery and citizens at large. His underplaying of the threat of Covid-19 — calling it a “flu” and resisting demands for early lockdowns — led to wastage of precious time and may have lost Pakistan the early initiative that could have controlled the spread of the virus.

“From the last week of March till mid-May, we were trying to figure out what our strategy should be,” admits Umar.

Army’s contribution

NCOC had been formed in March and the military became the fulcrum for the organisation. Officials say GHQ sent the best officers to NCOC. A three-star general was nominated as the chief coordinator with a two-star general to assist him. Planning Minister Asad Umar — with his corporate management background and gravitas within the federal cabinet — was seen as the best choice to lead the forum.

“The military high command sent War Course-qualified officers to the NCOC,” says a senior official. The Armed Forces War Course (AFWC) is a key barometer for promotion beyond the rank of lieutenant colonel. It is a hugely competitive course and a very small percentage of officers qualify for it. “Officers from the MO (Military Operations) Directorate were dispatched to the NCOC,” the official says. The MO Directorate is the nerve centre of the GHQ and top officers are usually posted to this directorate.

As the NCOC gathered momentum, the initial blunders of the federal government began to give way to clarity. NCOC became a self-sustaining platform drawing information and knowledge from provincial governments, in-house epidemiologists, data-modellers and other relevant officials.

“We were not in the loop on anything regarding Covid-19 policy,” admits a cabinet minister. It was as if the federal cabinet had outsourced the entire Covid-19 policy and implementation to the NCOC. Perhaps — given the unsatisfactory performance of the government thus far — this was a smart thing to do.

By mid-May, NCOC had finalised its strategy which comprised two basic aims: 1) Curtailing the spread of the virus while keeping at a minimum the loss to the economy; 2) enhancing health facilities. But by the time these twin objectives took shape, Eid was around the corner. That’s when the big decision came: open the bazaars.

‘Lowest point’

The consequences were devastating and the system reeled under the explosive pressure of the infection spike in early June. Everyone was rattled. “That was the lowest point for me,” confesses Umar, “when deaths per day hit triple figures.”

Since then, something has clearly worked. The government takes credit. Officials say Asad Umar has led the NCOC with single-minded focus with clear objectives rooted in data-reports, and well-defined outcomes measured in timelined delivery. This resulted in significant enhancement of the health infrastructure and effective utilization of the state machinery to enforce SOPs and implement smart lockdowns. According to officials, the key to this success were four measures: (1) Voluntary behaviour change by citizens prompted by aggressive government campaign, and probably genuine fear after the June peak; (2) SOPs’ compliance by people and enforcement by local administrations; (3) initiation of smart lockdowns (43pc of the cases were concentrated in 5pc of the population as per official estimates); and (4) closure of ‘high-density activity’ sectors like restaurants, cinemas and tourism places.

Realm of the unknowns

This may explain some of the reasons, but clearly there are more factors at play. However, they remain within the realm of ‘unknowns’. One expert who has tracked the spread says that in big cities 20-30pc of the population may have been infected and recovered without overt symptoms. He refers to a Punjab health department report that suggested up to 600,000 people may have been infected in Lahore alone. Since then this figure would have multiplied many times. “For high-immunity populations this may constitute early stages of herd immunity,” he suggests.

One senior doctor, who was frequently consulted by the government, says much of where we stand now remains unexplained. Is it something to do with our immunity? Has the virus mutated and become less lethal? No one has the answers yet.

For now, however, complacency has already begun to set in. Officials say this is alarming because two “super-spreading events” are approaching: Eid and Muharram. “We could witness a resurgence if we are not careful,” says a senior official.

Umar agrees. He says he is less worried about Eid and more about Muharram for the spread of the virus. “But we are in a better position administratively and otherwise than we were in the last Eid,” he says.

Pakistan may have an upper hand for now, but the battle against Covid-19 is far from over.

Published in Dawn, July 24th, 2020