On February 26, 2020, Pakistan confirmed its first Covid-19 case when 22-year-old Syed Muhammad Yahya Jafri became Pakistan’s first ‘positive’ case. Jafri had just returned from a 14-day trip to Tehran with a group of friends. During the last two days of his stay there, he began to experience two Covid-19 symptoms: extreme fatigue and persistent headaches.

“It was an illness I had never experienced before and it never occurred to me that it could be Covid-19. I was aware that a virus which had originated in Wuhan in December was spreading fast, but I had no idea it had reached other places including Iran,” remembers Jafri.

He learned about the virus at Tehran Airport, as he was waiting to board a plane for Karachi. Realising that he might have contracted the virus, Jafri started looking up symptoms of Covid-19 on different websites, most of which included shortness of breath, dry cough, and chest pains. “Thankfully I had none of them and this put my mind at ease.”

The day after his arrival, Jafri attended classes at the University of Karachi, but left within a few hours as his symptoms began to worsen. The following morning, he went to get tested at Aga Khan University Hospital, where he was advised to isolate in case he tested positive. “I did not find out that I tested positive from my doctors; instead, I heard my name, my CNIC and passport numbers, home address and travel history aired on multiple TV channels in the form of breaking news. I found this extremely offensive,” he recalls.

Thus, Jafri became ‘patient zero’. On the same day, another Covid-19 case was detected in Islamabad: both patients had one thing in common: they had recently returned from Iran. In just a span of weeks, Pakistan reported its first Covid-19 death on March 18, 2020 – Saadat Khan, a 50-year-old man who had returned from Saudi Arabia.

Lockdown Logs

By March 24, as the number of cases in the country passed 800, countrywide lockdowns began to take place. At the time, it was expected that the lockdown would end on April 6; until then, public gatherings, international, intercity and interprovincial travel were banned and offices, educational institutions and other commercial enterprises such as restaurants and malls were closed down. By April 2, 818 cases had been registered, with Punjab the most affected province with 1,114 cases. This led to the lockdown being extended until April 14, and it was announced that all educational institutions would remain closed till May 31, 2020.

Three Peaks in One Year

Pakistan experienced its first ‘peak’ shortly after the lockdown eased, on June 1, weeks after Eid-ul-Fitr and cases peaked at 6,825 (the highest number in 24 hours) on June 14. Given Pakistan’s fragile healthcare infrastructure, it was anticipated by many experts that the country would see the worst of the pandemic. However, following the first wave in June, the numbers began to decline, dropping to 300 a day in September, the month when Iran was reporting 2,000 cases daily and India 90,000. Then in October cases began to surge again, with 1,000 a day and crossed the 3,000 mark on November 24. By early December, the virus had claimed 8,487 lives across the country.

Currently, Pakistan is experiencing its third wave, which began in February, and on March 19, 2021, 3,876 cases were reported in 24 hours, the highest since January 13 when the count rose to 3,097 a day and 40 deaths reported within 24 hours. According to Dr Rashid Khan, (PhD in Medicine), Consultant, Mid City Hospital and Med East Hospital Paragon, this was partially due to the third UK variant, which is highly contagious and “a little stubborn” because it is immune to “traditional treatment”.

Are Pakistanis More Immune to Covid-19 Compared to Some Other Countries?

Despite the third peak, Pakistan still appears to be relatively less affected than other countries. To find out if this is actually the case and why, Aurora spoke to several healthcare professionals.

In response, all the epidemiologists Aurora spoke to believe there could be many factors working together but are quick to add that given it has been a little more than a year since the virus emerged, a lot of things at this point are just conjecture.

According to Dr Faisal Mehmood, Associate Professor, Section of Infectious Diseases, Department of Medicine, AKUH, Pakistan’s biggest advantage when it comes to fighting Covid-19 is the fact that it has a relatively young population as 60% are below 30. “We know that people who die from the disease tend to be older, so our age pyramid really works in our favour. Moreover, the infection came here later than the rest of the world and not in the high numbers as was the case in other parts of the world which attract a lot of tourists,” he explains. Mehmood believes that even before the first cases were detected in Pakistan, airports in the country began to monitor and quarantine people who were arriving from China and Iran. “Remember, every infection that you stop in the beginning means many more infections prevented.”

Dr Asma Nasim, Associate Professor of Infectious Diseases, SIUT, seconds Dr Mehmood’s opinion and adds that there could be several socio-cultural factors at play. For example, she says that in Pakistan the elderly do not socialise or go out as much as their counterparts in the West and prefer staying indoors. Furthermore, there are not as many retirement homes for the elderly which is the case in the West and this lessens their chances of infection. Moreover, she says in rural parts of Pakistan, infection rates are even lower because people there spend most of their time outdoors compared to congested indoor environments.

Khan, for his part, highlights another important factor. “Our diet plays an important role as well; most of our elderly people – and the young – consume organic, home-made food, compared to the West where junk and processed foods are the norm – and of course, we must not forget that the majority of our population lives in extreme unhygienic conditions and is forced to drink unsafe water so they have stronger immune systems.”

A Case of Low Testing?

An article in Dawn dated February 24, 2021, stated: “As Pakistan continues to see a fall in Covid-19 cases, a website [worldometers.info] has placed the country on the 29th position in the list of 30 countries that have conducted the most number of tests per million population (PMP).” According to the website, Pakistan carried out 39,136 tests per million and Israel topped the list with 1.27 million tests, followed by the UK (1.26 million) and the US (1.05 million). Compared to Pakistan, India conducted about four times more tests (152,821). Furthermore, several people also believe that the significant drop in the number of cases was due to underreporting on the government’s part. In Mehmood’s opinion, the most reliable metric is the death rate as it is hard to hide, although they are reported two to three weeks later. In this regard, as of March 17, 2021, according to ourworldindata.org, Pakistan and India’s death rate per million stood at 0.2 and 0.1 respectively, while those in the UK and the US stood at 1.8 and 3.7. This means that compared to the West, Pakistan’s death rate is relatively low, even if testing rates are low. “There could be some underreporting, and there will always be underreporting because we do not have a fool-proof method,” says Mehmood.

Zooming In On Treatment

As the disease has evolved, so has the treatment. “Since we had no prior knowledge of the disease in the early days, we followed the treatments that the medical community in China recommended,” says Nasim. Initially, doctors were warned by their Chinese counterparts not to use steroids as they might cause complications and suggested hydroxychloroquine, a drug which is used to treat malaria and arthritis, or erythromycin (an antibiotic). By April, they began to use tocilizumab, an immunosuppressive drug used primarily to treat arthritis. After research papers from Canada and the US declared hydroxychloroquine ineffective against Covid-19, its use was discontinued. By that time, steroids began to be used, as was remdesivir (an anti-viral medication); both continue to be used, in conjunction with anti-coagulants and tocilizumab, if patients do not respond to steroids.

As for the symptoms, Mehmood says he has not observed any major change in the last year. “What we have learnt is that symptoms vary according to age and sex. For example, older people tend to complain of cough and fever, while women are unable to taste and smell.” Other symptoms include body aches and a sore throat.

“We have definitely seen more men than women suffering from Covid-19; symptoms have been more or less the same but in the first wave more people complained of body aches and cough but during the second wave, an increasing number of people experienced chills, although this could also be due to the colder weather,” says Nasim.

The Vaccine Arrives

Clinical trials for a Covid-19 vaccine began as early as April 2020, and currently, at least 10 have been approved for use. These include AstraZeneca (manufactured in the UK), Can Sino (China), Johnson & Johnson (US), Kexing (China), Modena (US), Novavax (United States), Pfizer (US and Germany), Sinopharm (China), Sinovac (China) and Sputnik V (Russia).

Pakistan received its first consignment of half a million doses of Sinopharm on February 1, 2021, enabling the country to launch a vaccination drive for frontline healthcare workers. As of February 21, 72,882 frontline healthcare workers were vaccinated and other health professionals began registering for vaccination on February 22. The second phase of the campaign to vaccinate senior citizens began on March 10. The Drug Regulatory Authority of Pakistan (DRAP) approved the use of Sinopharm for people over 60, after the first consignment of AstraZeneca, due to arrive by mid-March was delayed. The question, however, is how effective are these vaccines against the virus and for how long will their potency last? “It is important to realise that all vaccines are almost equally effective in preventing death and severe disease. We want people not to die or become sick enough to come to a hospital. And these vaccines will work against new variants as well,” says Mehmood.

“The virus has been around for a little more than a year, and the vaccines have been developed in six months or so. As a result, none of the doctors can predict what will happen next, as vaccines usually require 10 to 12 years to be developed,” says Nasim and adds no one knows whether people will need to be vaccinated every year or not.

To Vax or Not to Vax

Experts are of the opinion that Pakistan’s biggest barrier is distribution since the country has no blueprint for adult vaccinations, and according to a Gallup PIMA study on ‘Vaccine Confidence’ conducted earlier this year, 59% of health professionals in Pakistan do not have access to the vaccine.

Mehmood says that the distribution of the vaccine within each province is the purview of each province. The system has been centralised through NADRA, and that healthcare workers were asked to register as soon as the vaccine arrived in Pakistan. Therefore, if a reported 80% have not been vaccinated, this may be because they have not registered, suggesting that the major challenge Pakistan is facing is vaccine hesitancy. This is not surprising given that the country’s paediatric vaccination efforts for various diseases such as polio have not been successful in the past.

“As a nation, we are anti-vaxers and conspiracy theories appeal to us. I am not saying the rest of the world is any different but we tend to believe such theories more,” says Dr Nasim, adding that at SIUT she had to persuade their young frontline workers to be vaccinated. The majority of people still subscribe to conspiracy theories that centre on Bill Gates embedding nano-chips in people’s bodies to monitor them, or that it will cause infertility.

Mehmood says “there are two types of people: those who are anti-vaxxers and they will never get vaccinated because they do not trust them and nothing will convince them otherwise. The other group is what I would term as ‘uncertain’; you have to address their concerns by telling them that millions of people have been vaccinated so far and are doing fine, while thousands of people contracted Covid-19 and died. They just need a little assurance.”

According to a survey conducted by Ipsos dated March 2021, two in five Pakistanis (40%) do not want to be vaccinated and 23% are ready to be vaccinated. For context, the number of people who want to be vaccinated according to the survey is higher in other countries such as Mexico (82%), Brazil (79%) and Spain (71%). The reasons as to why Pakistanis do not want to be vaccinated include side effects (23%), being “against the vaccine in general” (21%) and believing that the vaccine has been developed too quickly without adequate testing (19%).

The government has approved of commercialisation of vaccines which Mehmood thinks is a good thing and although no other country has so far approved the commercial availability of vaccines, he believes they eventually will. He adds that one cannot compare Pakistan to Canada, the UK or the US, which have purchased more vaccines than their population requires, a fact that may end up causing a global vaccination shortage. “I don’t want to speak for the government but every country wants vaccines for their population and that is never going to happen because of the amount of money involved, as well as issues of storage, distribution, manufacturing and other logistics. So let’s not put the entire burden on the government.”

Giving their final word, all doctors agree that Covid-19 is not going away any time soon. As to when it will reach a level that it will be considered a seasonal disease such as the flu depends on how well vaccines work and whether or not people continue to practise social distancing. “Masks are not going anywhere,” they conclude.