Pakistan has emerged as a Covid-19 hotspot in South Asia with one of the highest numbers of daily new cases. Its strategy to deal with the outbreak has included a full lockdown, a selective lockdown as well as zero restrictions on mobility.
Pakistani authorities have reimposed lockdowns in “emerging hotspots” of its biggest city, Karachi, effective on Thursday for two weeks as the novel coronavirus continues to implode in the country.
This followed partial lockdowns in areas in Lahore, Peshawar and other cities after the federal government said Covid-19 infections could multiply eightfold by the end of July and hit 1.2 million.
The announcement came eight days or 45,500 cases after the World Health Organization asked Pakistani authorities to impose "intermittent lockdowns" to curb the spread of the novel coronavirus.
With more than 160,100 cases, Pakistan is firmly inching up the rankings of countries with most infections, currently the 13th on the list.
We look at key things to know about Pakistan’s Covid-19 outbreak and lockdowns:
Mixed messages from those who lead
In times of crisis, people look to their government and community leaders.
The army and the civilian government are seen by the Pakistani public as equals – in some cases, the former is taken to be the heavyweight – with the clerics as the spiritual leaders.
Their mixed messages have resulted in conflicting guidelines and confusion on how seriously to take the deadly virus.
The government at first turned to Egypt for an Islamic ruling on banning congregational prayers in order to get Pakistani clerics onboard with mosque closures, announcing on March 26 limited capacity prayers.
When the clerics refused to back off, less than a month later, the government capitulated and allowed mosques to fully reopen.
This decision, despite an uptick in infections, resulted in crowds gathering for congregational prayers in Ramadan on a daily basis.
The government later lifted its countrywide lockdown on May 9, a period which saw some 2,000 new cases daily.
Khan justified his decision to end restrictions by citing economic stress and said the idea of a lockdown was forced by the elites.
On Sunday, Planning Minister Asad Umar warned cases could double by the end of June to 300,000, and reach 1 million to 1.2 million by the end of July if current trends continued.
Total cumulative deaths due to covid on 14th may : Pakistan 770, India 2,649. Cumulative covid deaths on 14th June : Pakistan 2632, India 9,485. Increase in deaths last month : Pakistan 242% India 258%. There is much we are still learning about covid spread and mortality.— Asad Umar (@Asad_Umar) June 14, 2020
Lockdown ended too soon
The WHO in a letter to Pakistani authorities last week stated the country did not meet any of the global body's conditions for lifting restrictions.
The WHO recommends six conditions for lifting restrictions, including the disease transmission being “under control,” being able to detect, test, isolate and treat every case and trace every contact, essential places having established preventive measures, and communities being educated, engaged and empowered to “live under a new normal.”
After the lockdown was lifted, people violated government guidelines on social distancing, wearing masks and gloves, as they thronged mosques and markets during Ramadan and ahead of the Eid festival in May.
Since then the South Asian nation’s infection rates have doubled from one-in-ten to one-in-five testing positive.
Testing rates remain insufficient
Though authorities have recently ramped up testing, it is still not enough and true numbers are thought to be higher.
It is “extremely important” to develop the capacity to conduct beyond 50,000 tests daily, the WHO letter stated.
Pakistan, a country of over 210 million people, has tested a maximum of some 30,000 people daily.
It has so far carried out at least 950,782 tests, testing 0.43 percent of the population.
Imran Khan is against nationwide lockdowns
The WHO had suggested a two week-on two week-off styled lockdown to control the rise in cases.
But Khan once again ruled out a nationwide lockdown, on Saturday.
One of the cities that will see partial restrictions is the densely populated eastern metropolis of Lahore, the capital of Pakistan's largest province Punjab. With more than 60,000 cases, Punjab has been hit the hardest by Covid-19 in the country.
A senior official said a number of areas of Lahore would be sealed for two weeks, with entry or exit barred, and government-issued safety guidelines would be enforced in markets using paramilitary forces.
Megacity Karachi and Peshawar followed suit, with hotspots under lockdown and renewed social-distancing measures.
Parts of Pakistan's capital Islamabad will see similar measures, provincial and national officials said, with more cities expected to follow suit.
Healthcare system not equipped to keep up with Covid-19
Pakistan is among countries which spend the least on healthcare.
Even before the coronavirus, public hospitals were understaffed, overcrowded and unsanitary.
Hospitals equipped to handle Covid-19 cases are now at full occupancy in major cities.
In Balochistan's city of Quetta, hundreds of doctors and paramedics protested in April against a lack of PPE or protective gear, only to get roughed up and arrested.
Balochistan's provincial government spokesman Liaqat Shahwani recently said authorities are still struggling to cope.
Earlier this month a leaked government report suggested there are nearly 700,000 infections in Lahore. Official testing drives put that numbers at a mere 31,000.
Doctors at several main hospitals in the historic eastern city said they were running out of beds, ventilators and other vital equipment.
"As the cases increase, more healthcare workers are also falling victim to the virus," said Farooq Sahil, a doctor at Services Hospital Lahore.
Khizer Hayat, chairman of the Young Doctors Association of Punjab, said facilities across the province needed help.
"Hospitals are running out of beds; there aren't enough ventilators given to us," he told AFP.
Frontline healthcare workers in Pakistan need PPE not your salutes. I am very scared for my colleagues & friends who have to deal with an incompetent government that doesn't care about human life. Give them #PPE atleast!#Westandwithhealthworkers#MayDay2020 #LabourDayMay2020 pic.twitter.com/jwDIWNTe7Z— Dr.Mahra Butt (@MahraButt) May 1, 2020
In the southern port city of Karachi, health centres are turning away the sick, with a large sign near the entrance of the Indus hospital, a massive tertiary facility, stating there was no room for coronavirus patients.
Another official at the city’s Civil Hospital also said the facility was at full occupancy, adding 1 in every three tests was positive in Karachi.
Cultural norms impact approach to healthcare
Khyber Pakhtunkhwa (KP) province has the highest Covid-19 death rate in the country but lags behind Punjab and Sindh in infections.
At 3.82 percent, KP's Covid-19 mortality rate is almost double the country’s average rate of 1.92 percent.
KP's fatalities cannot be blamed on a stretched health system as hospitals in the province are well below full capacity.
Hospitals there remain below 70 percent occupancy, with less than 50 percent of available ventilators in use, according to Dr Iftikharuddin of KP's health department.
There are several reasons contributing to KP's high death rate in the province, Iftikharrudin explained, including a higher sensitivity in recording deaths but not in registering cases.
People with mild virus symptoms or no symptoms were not being tested, he said, suggesting a higher infection rate than being recorded.
Fears of isolation also contributed to people staying away even if they were sick.
Family members report taking patients to the hospital by force when their condition deteriorates, and for many it is already too late.
Elaborating on the community’s hesitance to approach hospitals, Peshawar-based journalist Umer Farooq said many people steered clear of testing or a clinical diagnosis because they were fearful of dying alone. Funerals held under virus guidelines were against the culture and traditions of the people of KP, he said.
“People prefer to die in their own beds rather than one in a hospital, they prefer to be surrounded by their loved ones instead of medical staff. They want their funerals to be attended by a large number of people," Farooq said.
So they fear that if they visit a hospital and are tested then they were entered into the system the situation no longer remains in their own control.”
Iftikharuddin was confident the province's outbreak would peak and decline fast. Given KP's mean age is 22 years, he the community would be quick to achieve herd immunity as well.