For Pakistanis, a simple glance across the eastern border is a jarring reminder of how quickly a Covid-19 surge can become an apocalypse. India is now registering more than half of the world's daily Covid-19 infections—and the real total may be far higher, as many cases and deaths remain uncounted.
India's second Covid-19 wave has left much of its population breathless and its healthcare system in ashes. There are dire shortages of oxygen, medicine, and hospital beds, while funeral pyres of the dead burn endlessly. "This is not a second wave in India as much as it is a whole new pandemic," said Zulfiqar Bhutta, the founding director of the Institute for Global Health & Development at Aga Khan University in Karachi.
This is ringing alarm bells in Pakistan, which is also experiencing an uptick in cases. The country had 6,127 infections on April 17, the highest figure since last June 20. While the test positivity rate is very high—a sign of inadequate testing and uncontrolled viral spread—in major cities like Karachi and Lahore, areas throughout Pakistan's four provinces (such as Gujranwala, Mardan, Hyderabad, and Quetta) are also reporting high rates.
The impact is already obvious. Pakistan's hospitals are treating more severely ill patients requiring oxygen than at any other point during the pandemic. Another grim milestone was reached on April 27 when a record 201 deaths were registered in a single day. At one point, 90 percent of the country's oxygen supply was in use.
Pakistan finds itself teetering on the brink as the holy month of Ramadan closes and the Eid al-Fitr holidays approach. Spooked by the daily Covid-19 horror show next door in India, Prime Minister Imran Khan's government is taking preventative measures to curb a cataclysmic third wave. But it faces formidable headwinds: pandemic fatigue, population density, relaxed Ramadan restrictions, contagious variants, limited genomic surveillance capabilities, a glacial vaccine campaign, and a starved healthcare infrastructure. As Federal Minister Asad Umar, who helms the nation's pandemic response, tweeted on May 8, "Danger is higher than ever and knocking at our doors."
Unlike much of the world, Pakistan's first two waves of the pandemic were much milder than experts forecasted. Many theories, none conclusively proven, have emerged on why the country remained mostly unscathed. But India's story shows the limits of these supposed inherent advantages. "We now know that it was wishful thinking that populations in the subcontinent have some underlying protection from rapid spread and high mortality," wrote Mishal Khan, an associate professor in the Faculty of Public Health and Policy at the London School of Hygiene and Tropical Medicine.
While Pakistan's more forgiving first waves spared lives, they also defanged the virus in the minds of the public. A Gallup poll from May 5 found that 64 percent of citizens thought the coronavirus threat was exaggerated.
The complacency and outright Covid-19 denial have led many to flout critical and proven public health measures, referred to as Standard Operating Procedures (SOPs), such as masking and distancing in all corners of the country. "The average Pakistani is not wearing masks. I was just in Pakistan, and I think one out of ten would wear a mask," said Ayesha Jalal, a historian and professor at Tufts University. "You're really rejecting science by not accepting the basics."
Though the army has been enlisted by the government to aid the police and law enforcement agencies in enforcing SOPs, the religious conservatives remain recalcitrant and unapologetic as mosques teemed with adherents during Ramadan and thousands of people went without masks in Shia religious processions.
The government has been reluctant to limit religious gatherings, fearful of a backlash. "I worry about Covid, of course, but the increasing influence of the clergy has implications across the board for this country. The person in the street is also in line with the thought process of the clergy," said Sameen Siddiqi, a former director of Health Systems Development at the World Health Organization.
These super-spreader gatherings have a new significance because of circulating variants. Outside of the highly contagious UK variant (B117) already responsible for 70 percent of Pakistan's current cases, the South African (B1351) and Brazilian (P1) mutants have also been detected in the country. And though the insidious Indian double variant (B1617) has yet to be spotted, it is already lurking in neighboring countries.
But these are only scattered pieces of Pakistan's entire variant puzzle. Apart from a few institutions, the health system's anemic genomic sequencing capabilities leave it in the dark about how prevalent a certain variant is in the population or whether other, more punishing strains are spreading within its borders. According to the GISAID Initiative, a global database for coronavirus genomes, the country has sequenced only 0.022 percent of its almost 870,000 cases, placing it near the bottom of global rankings.
At a moment when variants will define future waves of infection and inform pandemic strategies, the absence of this data not only affects Pakistan but also the greater world. "If you're flying blind, it increases everyone's risk," said Saad Omer, the director of the Yale Institute for Global Health.
Pakistan's vaccine supply has been sluggish. Because India's behemoth vaccine industry suspended the export of inoculants to Covax, a World Health Organization program to ensure equitable distribution of vaccines to poor countries, in order to fulfill its own domestic requirements, Pakistan has had to scramble to find other sources of supply. It has cobbled together Chinese vaccines through donation and purchase, and has sanctioned a private sector where the Russian Sputnik V vaccine is available for sale.
Less than 1 percent of the population is vaccinated at present, but the vaccine campaign will be somewhat buoyed by the first Covax batch that landed only days ago and by plans to domestically produce China's CanSino vaccine. Crucially, per a March Gallup survey, vaccine hesitancy also appears to be softening as 65 percent of Pakistanis are now seeking a jab. All said though, widespread vaccination of consequence may not be achieved until some time in 2023.
Any avalanche of infections that may emerge from a constellation of these risks is likely to incinerate a rickety healthcare system, funded by a meagre 0.7 percent of Pakistan's GDP. Already, hospitals in places like Lahore and Islamabad have buckled as severe cases grew. "It is about having strong systems. Our systems will not be able to deliver, God forbid, if we reach even a bit of what is happening in our neighboring country," said Siddiqi. "The public health measures have to be reinforced. That is our bottom line, that is where we need to be putting our resources."
Cognizant of its inability to absorb even a fraction of India's ongoing Covid-19 surge, Khan's government has opted for preemption. A partial lockdown has been instituted from May 8 until May 16 in order to restrict the typical interaction and mass movement of people seen during Eid al-Fitr celebrations. These measures were preceded only days before by a decision to reduce incoming international flights from May 5 until May 20 by 80 percent.
"The government has been proactive. It would be irrational to assume that what is happening in India will not touch Pakistan," Omer said. "One recipe of the surge is what happens around Eid as people mix within cities and they travel. That seeds the outbreak nationally. In these kinds of situations rural areas get infection and it burns through the village."
Pakistan's disadvantages and missteps in the past year are not unique; they are the default in much of the world. The pandemic has particularly bedeviled complacent countries that have tragically misjudged their vulnerability to the contagion. But at least Pakistan's government appears to be reckoning with its frailties and taking heed.
While the world's gaze is fixed on India, how Pakistan's pandemic trajectory changes in the coming weeks will be of global import. Though the country does not possess the economic or strategic cachet of its neighbor, any distress call from Islamabad must be answered with vaccines, supplies, and similar alacrity. "They [the world] will likely not respond with the same degree of fervor as they have with India. The market in India is very attractive. India looks good in the eyes of the world because of an international anti-Pakistan narrative," Jalal said. "Should they care? Yes. Until and unless all of us are safe from this disastrous disease, none of us are safe."
Jalal Baig is a physician and writer based in Chicago. His work has appeared in the Washington Post, NBC News, The Atlantic, Guardian, Vice, Slate, Religion News Service and elsewhere
Disclaimer: This article first appeared on Foreign Policy, and is published by special syndication arrangement