20200910 pakistan
People visit a mobile phone market in Lahore. Pakistan’s low number of cases has baffled public health experts. Image Credit: AFP

Islamabad: During the peak days of the coronavirus, the Benazir Bhutto Hospital in Rawalpindi had nearly 500 patients. Many with severe symptoms were turned away as the facility was already filled beyond capacity. The situation was so dreadful that frontline healthcare workers were being infected with COVID-19 every day. Today, the same hospital has zero coronavirus patients.

How did this happen? Pakistan’s COVID-19 victory has been described as “a bit of a mystery” as the country witnessed a perplexing yet steady drop in the virus cases just two months after the mid-June peak of around 6,800 cases in a day to a few hundred in September. With the spread of the virus now slowing down and demand for hospital care and testing dwindling, the country lifted most restrictions by mid-August as the pressure eased on the healthcare system.


Minister Asad Umar, spearheading the fight against COVID-19, had cautioned that around 1.2 million people could be infected in Pakistan by the end of July. But the reality turned out to be not as bad. What happened between June and August? To answer the big question “How Pakistan won the battle against COVID pandemic?” Gulf News talked to leading experts to understand the strategy adopted by the country of 220 million with 299,200 infections and fragile healthcare system to defeat the virus.

Rapid response teams in Islamabad actively working to track and trace suspected COVID-19 patients. Image Credit: Supplied

Factors behind virus decline

Health officials, medical practitioners, and researchers believe that several environmental factors and preventive actions by Pakistan government such as smart lockdown helped diminish the intensity of the virus. Some experts indicate factors such as youth bulge and strong immunity against the contagious diseases could be the two most reasonable scientific causes behind the remarkably lower COVID-19 fatality rate in Pakistan as compared to the developed countries.

Dr. Faisal Sultan, infectious disease specialist and Prime Minister’s special assistant on national health services, says “Pakistan government’s coordinated and coherent strategy and data-driven decision making along with contact tracing and smart lockdowns” helped ease the pressure. However, additional “biological and environmental factors remain unknown factors too”, he added.

Dr. Faisal Sultan

No scientific explanation

The medical community too could not come up with a scientific explanation. When asked the reason, the Vice-Chancellor of Jinnah Sindh Medical University, Karachi Prof Dr. S.M. Tariq Rafi responded: “To be honest, nobody knows this answer exactly.” He believes that “it was a combination of mainly two factors, the partial lockdown imposed by the government and the precautions observed by the people on their own,” he said.

Prof Dr. S.M. Tariq Rafi

Natural factors and health equipment boost

The virus first reported on February 26 attained its peak in Pakistan on June 14 when 6,825 cases were reported in a single day and highest number of 153 COVID-19 fatalities on June 20 after which the country started witnessing a surprising gradual decline. Dr. Rafiq Khanani, President of Infection Control Society of Pakistan (ICSP) told Gulf News that some possible natural factors behind the decrease in cases include “the rise in atmospheric temperature, the increase in the index of ultraviolet rays in the sunlight, change in wind speed and pressure” across the country.

Lockdown and precautions

Dr. Tahir Shamsi, Dean and Chairman of National Institute of Blood Diseases Karachi, who led the plasma therapy trials in Pakistan, said that the spike after Eid Al Fitr scared the people to the extent that they “started adopting precautions like social distancing, frequent use of sanitizers, and masks religiously.” Dr. Khanani also thinks that the lockdown, compliance of social distancing rules, suspension of public transport and ban on gatherings are some key elements. “In the meantime, Pakistan also enhanced its capability and strength to beef up its fight against the coronavirus with the availability of crucial equipment like ventilators and PPE (personal protective equipment) kits,” said the ICSP president.

Dr. Tahir Shamsi

Young population and strong immunity

Pakistan’s significant young population has been described as one possible reason as the youth remained relatively less affected by the virus. Dr. Tahir Shamsi suggested, “youth especially those having age up to 23, which represent an enormous ratio of Pakistani population, had unknowingly developed anti-bodies against the viral disease with the mass community spread of the COVID-19 in Pakistan.” Strong immune system is another factor, says Dr. Tariq Rafi. While another key factor behind low COVID-19 mortality rate in Pakistan could be the “possibility that a weak strain of virus remained active here” he added. Pakistan’s COVID-19 mortality rate is about 2.16 per cent, compared with 6.9 per cent in Canada, 9.3 per cent in France, and 12.7 per cent in Italy.

Coherent, centralized and coordinated strategy

After a month in disarray, Pakistan in April formed National Command and Operation Center (NCOC) utilizing the combined resources and expertise of civil and military institutions to combat the deadly virus with active support from National Disaster Management Authority (NDMA). The Track, Trace and Quarantine (TTQ) strategy to trace contacts of positive cases and quarantining those infected proved successful than a complete shutdown, officials say. The centralized and coherent evidence-based and data-driven approach led to flexible coordination among the provinces and effective containment of the virus.

Smart lockdown

Pakistan introduced a “smart lockdown” technique under which only those hotspot areas were sealed where infections were reported as the country’s economy could not afford a complete lockdown. Prime Minister Imran Khan says the smart lockdown was initiated to strike a “balance between lives and livelihood”. Country’s biggest social safety net program was also announced to disburse Rs145 billion emergency cash among 12 million daily wagers affected by the pandemic.

“The cash assistance and the lockdown enforced by the government and the charity programs by ordinary people helped curb the spread from urban to rural areas with massive population and limited health facilities” Dr. Saima Zubair, who works at Kulsum International Hospital in Islamabad, told Gulf News. “This is the reason that Pakistan fared better than its neighbour India despite many similarities of the weather system and healthcare services” she added.

Dr. Saima Zubair

Cases decline despite low testing

Pakistan has so far conducted 2.8 million tests, which the experts consider far lower than required. A recent study by Aga Khan University has revealed that nine out of 10 COVID-19 patients in Karachi – country’s COVID-19 epicentre – were asymptomatic, based on a study consisting of 2,000 participants.

Despite the falling testing levels, “The decrease in positive cases is real as the labs are witnessing less positivity and hospitals are seeing fewer patients which tells you the number of cases have come down” says Dr. Saima who during the peak days treated and consulted hundreds of patients in Islamabad and twin city Rawalpindi. “This is truly God’s blessing. There is no scientific explanation” she remarked.

At Civil Hospital Karachi, the city’s biggest isolation and treatment facility, with 223 beds for COVID-19 patients and 39-bed ICU facility, the bed occupancy remained up to 99 per cent of which nearly 90 per cent have recovered, said Dr. Khadim Hussain Qureshi, hospital’s former medical superintendent. The health facility played a key role in enhancing COVID-19 testing facility offered by the Sindh government. During the April-June period, protection of the doctors and medical staff of hospital and availability of PPE kits and N-95 masks remained a major challenge due to their constant exposure to the infected patients.

Islamabad’s strategy

Pakistan’s capital city of nearly 2 million managed to drastically reduce infection with strict measures mainly improved testing and smart lockdown. Islamabad’s positivity ratio (the number of people that test positive out of all tested) and the fatality rate, both are less than 1 percent, officials say. By September 8, a total of 285,171 tests were conducted which means 28 per cent people or one of every five Islamabad residents were tested for the virus, informed Dr. Zaeem Zia, Islamabad district health officer (DHO).

While many describe the reduction in infection “a mystery” Dr. Zaeem credits his dedicated team and the city administration working round the clock to trace suspected patients for bringing down the number of cases. “The surveillance team is alert 24/7. As soon as one positive case is reported, they are immediately isolated and put into quarantine and their immediate family tested” he shared. More than 48,000 houses were quarantined and 40,000 contacts traced. Some of the key measures that Islamabad adopted to contain the spread are as follows:

1. Rapid response teams to track and trace patients and ensure home quarantine guidelines.

2. Strict lockdown in selected areas for a limited time where people are not allowed out of their homes except to buy essentials.

3. DHO team and volunteers ensuring the provision of food, medical and critical supplies such as oxygen cylinder in areas under lockdown.

4. Ensuring implementation of health guidelines such as wearing masks and fining individuals and businesses that violate the orders.

6. Shutting down shops, business, restaurants where a few cases are reported.

Confusion, fear and stigma

Despite the strict rules, fines, awareness campaigns and lockdown, Pakistanis faced confusion, anxiety and stigma related to COVID-19 cases since March. “During all this period, people generally sought treatment for COVID-19 on a non-scientific basis,” in the absence of a clear-cut treatment, says Karachi-based health reporter, Tufail Ahmed. “Some consumed Vitamin C tablets as others took anti-allergy pills to treat COVID-19,” said the journalist, who covered COVID-19 pandemic in Pakistan since day one.

Fear and stigma fuelled by misinformation gripped the country due to which some people hid their symptoms fearing “social boycott from family and friends.” Some did not take the disease seriously due to the conspiracy theories spread on WhatsApp. Some claimed that the virus is fake and doctors are getting paid for every positive COVID-19 test. Others said the government was creating hype about the disease to get donations. All of which only added to the worries of doctors and health officials.

Battle not over yet

Pakistan is fortunate enough to record a massive decline but experts warn people should adopt the “new normal” and follow key precautions until a vaccine is here. The strong devotion of doctors and nurses, swift measures by the government to support the healthcare system and rapid actions taken by the officials to ensure health guidelines has helped Pakistan nearly win the fight against the coronavirus but experts say the battle is “not over yet”. The threat of a second wave looms if people become “too relaxed” and stop following the three golden rules: wearing masks, frequent hand washing and maintaining physical distance.