Pakistan & India Two Public Value Paths in the Coronavirus Pandemic

Author Name: Dr. Usman Chohan      21 Sep 2020    

 

Pakistan & India: Two Paths in the Coronavirus Pandemic

The coronavirus (Covid-19) pandemic has had an enormous global fallout, and every region has had to brace for public health crises as well as economic devastation. Although the distress of the pandemic has been felt worldwide, the ability of countries to respond to the pandemic, and their success in mustering an adequate response, has diverged significantly across countries. This is true even for countries that have comparatively similar levels of development, similar demographic characteristics, comparable public health and vaccination resources, and comparable social norms.

Figure 1: India and Pakistan against the Pandemic (Cases)

One particularly noteworthy comparative case study in this regard is that of India and Pakistan. At the face of it, they exhibit commonalities in demographics, resources, norms, and developmental trajectories. Yet Pakistan’s coronavirus response has been extraordinarily successful, at least in the initial phase (February-August 2020), while India is facing catastrophic losses in terms of both public health and economic outcomes. How can two otherwise comparable countries fare so differently? This working paper first draws upon the similarities in terms of structures and endowments that both possessed, in order to stress in the second half how India’s response fared so poorly when compared with that of Pakistan.

Figure 2: India and Pakistan against the Pandemic (Deaths)

The differences, as this paper finds, emanate from the manner in which the spread of the virus was curtailed without transmission into rural areas. India’s abrupt and poorly managed initial response, followed by an exodus of desperate Indians deep into the countryside, provoked colossal community transmission. That community transmission has now spread into regions where public health facilities are unable to cope. Meanwhile, Pakistan kept its lockdowns targeted, and put its population in quarantine wherever they resided, curtailing mobility and spread into the rural areas. In essence, the paper argues, it was a difference in public managerial leadership that caused public value destruction in India and public value preservation in Pakistan, and the paper examines the three actors of public value theory (politicians, public managers, and civil society) in that regard.

Figure 3: The cumulative confirmed deaths in 4 large countries

The Structural Similarities

Prima facie, both countries are South Asian neighbors that confront similar challenges. On the demographic front, both countries have comparatively young populations. In Pakistan, 70% of the population is below the age of 29 (Artaza 2020), while in India the number is nearly as high at 65% (Arsanalp et al. 2019). In addition, both have small proportions of elderly people in the population, with Pakistan’s over-65 population accounting for 4.2% of the total and India’s accounting for 5.3%. This is advantageous because young people are comparatively less affected, both in terms of severe symptoms as well as fatality rates, compared to elderly people. It was detected early on that coronavirus has a disproportionate impact on the elderly and is comparatively lenient with the young (see Liu et al 2020). As Lian et al observed, the coronavirus death toll was disproportionately to be found in older cohorts, even when young people might possess a higher viral load (2020).

The physiognomy of both populations, although different within various subgroups, is also comparable in that both countries have low obesity rates and have similar dispositions to common diseases such as diabetes and thalassemia.[1] Covid-19’s death toll accentuates on the comorbidity of factors such as obesity (see Simmonet et al 2020), and so having an obesity epidemic would immediately create a larger risk of Covid-19 deaths (see Kalligeros et al 2020). Fortunately, the obesity rate in Pakistan is a mere at 8.6% (ranked 141st in the world), while India’s is one of the absolute lowest in the world at 3.9% (ranked 187th). This would also prima facie accord an enormous advantage to both countries in terms of a reduction in the complications that would arise in contracted coronavirus cases.

Figure 4: Daily Positive Rates in Asia

Vaccination rates in both countries are also comparable when looking at immunization through BCG, which is hypothesized to accord a “non-specific immunity” to coronavirus (Safdar 2020). As a paper by Iqbal (2014) highlights, BCG provides a non-specific immunity against several maladies that afflict the developing world, including tuberculosis and leprosy. According to the WHO database on BCG immunization by country, in 2018 India had a population coverage of 92% and Pakistan had an 86% coverage, both of which would be considered high. On this point, although the precise relationship of BCG vaccination to Covid-19 through a non-specific immunity requires more rigorous analysis, it remains a notable hypothesis that BCG might have assisted countries such as Pakistan with low fatality rates (Safdar 2020).

Beyond the physiology of the citizens of both nations, there are social norms that characterize not just India and Pakistan but also other countries of South Asia, West Asia, and even the developing world at large. One of these pertains to the norms of urbanization, which is a notable and rapidly increasing phenomenon in the developing world (see Bertinelli and Strobi 2003), so much so that the relation of chronic diseases to urbanization in the developing world is seen as a “quantifiable phenomenon” (see Allender et al 2008). Urban population percentages are similar between both countries, with Pakistan’s urban population at 37% and India’s at 34%, according to the United Nations Population Division (UNPD 2019). In either country, with the exception of a few planned urban centres such as Islamabad in Pakistan or Chandigarh in India, as well as special zones in major cities, much of the urban development in both countries has occurred in a generally ad-hoc and unplanned manner (Tauhidi and Chohan 2020). Such urban design is characterized by small households separated by discrete entrances in low-rise semi-permanent construction.

Table 1: Comparative Summary Statistics for Pakistan and India

Parameters

Pakistan

India

Population*

210,000,000

1,353,000,000

Total Cases*
(world ranking)

299,000 (17th)

4,482,000 (2nd)

Total Deaths*
(world ranking)

6.300 (24th)

75,000 (3rd)

Young Population*
below 29 years

70%

65%

Elderly Population*
above 65 years

4.2%

5.3%

Obesity Rate

(world ranking)

8.6% (141st)

3.9% (187th)

Urban Population

37%

34%

BCG Immunization Rate
% of population

86%

92%

Physicians
per 10000 people

9

8

*Approximate figures, as of mid-September 2020
Sources: Pakistan Bureau of Statistics, World Health Organization, Ministry of Health (India), Census Bureau, United Nations Population Division, Our World in Data, Ministry of Health (Pakistan), World Bank Databank,

This is advantageous to the extent that it prevents the concentration of multiple households within the same confinement, as in apartment buildings or other high-rise constructions. In India, however, larger cities are increasingly characterized by high-rise developments that lead to the common spatial habitation of larger numbers of people, which in turn creates hot zones within such buildings such as the elevators, stairwells, and lobbies. As Bose notes, many high-rise buildings were at an extreme risk in India because of the common spaces through which large numbers of people would need to pass in high-rise constructions (Bose 2020), a problem that was not found in Pakistan due to largely low-rise construction.

That said, the rural population of both countries is similar in proportion, a point that will be discussed in the next section as extremely important in differentiating both countries’ coronavirus success by preventing rural outbreaks, where public health facilities are few, sparse, and ill-equipped. Indeed, both countries face common shortages of physicians in their healthcare systems, where Pakistan has 9 physicians per 10,000 people and India has 8 per 10,000, both numbers being worryingly small.

A further point of interest in social norms is cultural conservatism and traditional gender roles. Both India and Pakistan have strongly marked cultural conservatism, with Pakistan ranking as an exceptionally conservative country,[2] although such a general statement should be matched with the recognition of the cultural kaleidoscope that characterizes both nations (for Pakistan see Abou Zahab 2020; for India see Panda and Gupta 2004). Without resorting to value judgements about the merits of conservative societies, there is an epidemiological aspect to the mobility of conservative norms that warrants attention.

In such societies, it is generally uncommon for women to hustle about in the public sphere, even more so in Pakistan than in India. Their presence is most apparent in the private sphere, marked by traditional gender roles (Abou Zahab 2020). Because of this, they are much less likely to come into contact with a coronavirus carrier during some form of movement or transit, and as scientists have observed, there is a disproportionate exposure of men to the coronavirus in Pakistan than of women (Waris et al 2020). With half the population being women in any significantly large sample, the fact that half the population is kept in a relative state of private sphere is itself a de facto semi-quarantine. This paper does not express a value judgement about such social norms, but highlights the reduced probability of coronavirus transmission as a possible consequence.

So, glancing at such commonalities, one would be prone to hypothesizing that their responses to coronavirus and relative outcomes might be somewhat similar. In fact, it might have been a logical prediction at the beginning of the pandemic that both countries might have been in considerable trouble. The warnings for both countries at the beginning of the pandemic, and particularly for Pakistan, were indeed very dire. An algorithm designed at Imperial College London in early 2020 predicted that, in a worst case scenario, Pakistan would suffer 79,000 deaths by August 10, 2020, and if left entirely unchecked, by January 26, 2021 the death toll would reach an astounding 2.3 million (Mangwat 2020). The same algorithm predicted that by January 26, 2021, total deaths would be a colossal 14,244,379 without intervention.

Pessimism on the public health and economic fronts was exacerbated by the fact that propaganda and blame-game tactics also overshadowed international cooperation efforts (Budhwani and Sun 2020; Chohan 2019a).[3] Meanwhile, despite intense efforts to develop a workable vaccine (see Callaway 2020), as of mid-September 2020,[4] the clinical trial phase was still the preponderant stage for most efforts (Chen 2020). As the table below indicates, however, the contrast between Pakistan and India could not be more different.

Table 2: Cases and Deaths in Pakistan and India

Parameters

Pakistan

India

Population*

210,000,000

1,353,000,000

Total Cases*
(world ranking)

299,000 (17th)

4,482,000 (2nd)

Total Deaths*
(world ranking)

6.300 (24th)

75,000 (3rd)

Sources: World Health Organization, European CDC, Our World in Data

By September 2020, more than seven months after the first recorded case, Pakistan’s Covid-19 toll stood far below what had been feared early on. A far cry from the doomsday algorithm of the Imperial College, Pakistan had recorded only 6,300 deaths by mid-September (ranked 24th in the world), which was 90% less than what had been foretold in the case of reckless governmental and societal abandon, while its total cases were also vastly lower at less than 300,000 (ranking 17th in the world). By abysmal contrast, India had nearly 4.5 million cases, the second worst in the world after the United States, and a whopping 75,000 deaths, the third worst carnage in the world. At the same time, while Pakistan’s case and death curves were flattening well before September (after 90 days, in fact) India’s cases and deaths showed absolutely no signs of abating.[5] How could two countries who might otherwise be considered comparable in many key aspects show such wild differences in their coronavirus outcomes? The following section points to the public managerial, political, and civil society responses (i.e. public value stakeholder responses), that explain the difference, particularly in rescuing the rural population from the pandemic.

The Key Difference: Public Value Response

Public Value Theory (see reviews in Chohan 2019b, 2020e) contextualizes the need to create and preserve value for society through the cooperation of three key stakeholders: public managers (bureaucrats), politicians, and civil society. Each of these has some contribution in explaining the differences between the Indian and Pakistani outcomes in the pandemic. This section first highlights Pakistan’s success, and then contrasts this with the Indian failure and public value destruction.

Pakistan

In Pakistan, the political leadership and public managerial setup took the crisis very seriously from the outset. The Government of Pakistan was proactive in initiating a program of “smart lockdowns،[6] which refers to a series of targeted sectoral closures for specific periods of time (Farooq et al. 2020). The advantage of such an approach was that it did not paralyze entire cities, but rather reduced the mobility of residents in specific areas where the risk of transmission might have been higher. Living in a zone outside the national capital, I saw firsthand how the movement of people out of the cities was kept to an absolute minimum, whereby only people who could prove their residence in an area outside the city would be allowed to travel specifically to such a zone.

Epidemiological modelling (see Vega 2020) suggested that such a smart-lockdown approach might yield better trade-offs between “lives and livelihoods” (see Chohan 2020c-d). As an example, specific sectors of the capital Islamabad were tentatively sealed of including G-6, G-7, and the I-Sectors. At the same time, Prime Minister Imran Khan pointed to the important trade-off between public health outcomes and economic revival, while also advocating for international debt relief for the developing world, and cooperation among countries to fight the virus. Observing keenly the data that was coming from Wuhan, Pakistan not only kept its citizens residing in China under the care of the Chinese (Bengali and Sahi 2020), but also drew lessons from their early epidemiological strategy to implement locally despite more modest resources.

One factor that has been largely dependent on the attitude of the administration was its political will to combat the coronavirus, shunning conspiracy theories and adopting protective behavior (see Allington et al 2020). In Pakistan, although conspiracy theories regarding coronavirus abounded, and the public was an unruly disposition in not always taking government instructions seriously (Minhas et al 2020), the administration itself was not at the mercy of denialism. This is a credit to the Pakistani government for taking the pandemic seriously and with due regard for the destructive epidemiological potential of careless actions.

To mobilize a public administrative response, the Prime Minister had forged a task force with public health experts, and created a coordination mechanism that included all provinces as well as the center, and drew upon civilian and military resources to attempt as proactive a response as possible given the meagre resources available (Anser et al 2020). This national level coordination was far different from that observed in the United States where state-level responses came in all sorts, and various states even sought to form alliances for common responses in the absence of federal support (see Jerningan 2020).

Continued political and administrative sobriety in Pakistan in the face of the challenge helped with the coronavirus response to an extent that is difficult to overstate (Raza 2020). Yet the two public value agents of politicians and public managers were also bolstered by the third pillar of public value: civil society. Where the state may fall short, the people must come to one another’s assistance, and in Pakistan, it is often observed that charitable organizations and civil society groups exhibit a proactiveness in assisting the poor and the needy (Malik and Rana 2020). The early coronavirus lockdowns put immense pressure on the public sector to muster a response, but civil society organizations mobilized quickly to assist the poor with meals other resources to help them weather the storm (Malik et al 2020).

This meant that, even in a country where public finances were inadequate in terms of scope and coverage, people could come to one another’s aid and combat the economic threat posed by Covid-19. Highlighting this in Pakistan’s case is important because the burden borne by civil society groups was proportionately larger due to the comparatively direr public sector resource constraints. Thus, one could observe a public value trinity in Pakistan between public managers, politicians, and civil society.

This helped to bolster what was ultimately the single biggest factor in Pakistan’s battle against coronavirus: the absence of rural transmission. One major fear that persisted at the onset of coronavirus in Pakistan was that, should the virus spread to the rural areas with backward healthcare facilities and substandard access and equipment, the devastation would have been far greater (Anser et al 2020; Farooq et al 2020). It was heartening to see, then, that transmission to rural areas remained largely curbed, and the coronavirus pandemic was a largely urban phenomenon in Pakistan (Malik et al 2020). Pakistan only has 9 physicians per 10,000 people and the number is far lower if disaggregated to the rural population, while 63% of the population lives in such areas. As WHO indicators point out, there are various sorts of deficiencies of healthcare provision in rural areas that would have exponentially worsened the damage of coronavirus in Pakistan. Barriers to movement and targeted lockdowns, as mentioned above, helped to confine the virus largely to the urban areas of the country, thus alleviating a much greater worry.

India

In India, a very bleak situation emerged as of September 2020. With four and half million cases and 75,000 deaths, the coronavirus numbers continued to show that the carnage was not to abate but rather spread relentlessly. In addition, the second-quarter GDP contraction (April-June 2020) versus the previous year was so devastating at -23% as to defy belief. At the root of the problem was public value destruction involving all three stakeholders. India is no stranger to imposing brutal lockdowns, as it did over the occupied territory of Kashmir on August 5th, 2019, in blatant disregard of United Nations (see Chohan and Aamir 2019).

Putting 8 million people in an open prison, with nearly a million foreign occupation troops on the ground, the prototype of a lockdown horror story was put into place by the Modi government 6 months before the pandemic broke out (Chohan 2020j). With this vicious streak characterizing Delhi’s notion of what a “lockdown” was, it announced in the last week of March 2020, at only four hours’ notice, that the country would be closed down totally for 21 days (Gettleman and Schultz 2020).

At four hours’ notice, it is hard for anyone to get home and pack up, let alone prepare for a 3 week complete shutdown. Yet “every state, every district, every lane, every village will be under lockdown,” Mr. Modi said. Thus it was, that society was forced into paralysis without remedial measures for the public. As Gettleman and Schultz warned, “long lines of migrant workers streamed out of recently closed railway stations, with thousands of men, almost none wearing masks, marching close together to far-off villages, potentially spreading the virus deep into the countryside,” (2020). Unlike the strong civil society response, as one could expect in Pakistan, in India many lower caste members and rural migrants feared they would starve in such circumstances (Chidambaram 2020). As observed by Chidambaram, “we will never know how many people died of starvation, because no state government will admit to starvation deaths,” (2020).

There was thus the compound mental health distress of both confinement and/or flight into the countryside (Das and Paital 2020, Kumar and Dwivedi 2020). There was therefore a mass exodus from the cities deep into the countryside, which generated not just external infusions of viral load but also a significant community transmission (Davey et al 2020). Taking coronavirus from the cities towards the deep countryside (rural Uttar Pradesh, Orissa, and Bihar as examples) meant that there would be enormous multiplicative effects of transmission.

Upon return later on to the cities, the migrants brought the virus back into urban areas with a vengeance. In addition, unlike national coordination mechanism for coronavirus in Pakistan, it was the states that had to separately muster responses to the pandemic in India. This led to a few success stories such as the Communist-led southern state of Kerala (Udhaya Kumar et al 2020), but many states such as Maharashtra saw their health systems failing and public managers unable to cope (Bannerjee 2020). The following table highlights some important states and their cases and deaths as of mid-September.

Table 3: Coronavirus’ toll in certain major Indian states

State

Cases*

Deaths*

Maharashtra

991,000

28300

Tamil Nadu

491,000

8300

Karnataka

440,000

7100

Andhra Pradesh

547,000

4,800

Delhi

209,000

4,700

Uttar Pradesh

299,000

4300

West Bengal

196,000

3800

Gujarat

110,000

3100

Punjab

74,600

2200

Sorted by Deaths. Source: Ministry of Health and Family Welfare
*Rounded figures

 

By sending the public in flight to the countryside where healthcare facilities would not be adequate, the Indian government created vast pools of community transmission. In addition, financial programs set by the Modi government, including the Prime Minister’s Citizen Assistance and Relief in Emergency Situations (PM-CARES) Fund have been mired in corruption, a lack of transparency, and embezzlement (Venkat 2020). Despite rampant use of rhetoric by public managers and politicians, the numbers (very likely understating the toll) still speak for themselves.

Conclusion: Two Paths to Battling the Pandemic

Both India and Pakistan exhibited common structural characteristics that would have helped them confront the coronavirus pandemic at the outset, including a young population pyramid, low obesity rates, widespread vaccination programs (BCG), largely low-rise construction, and conservative cultures. Yet the outcomes of both countries in terms of cases and deaths could not be more different. These points can be framed in terms of Moore’s strategic triangle, as in Figure 4 and 5.

Figure 4: A Strategic Triangle Approach to India’s Coronavirus Efforts

Figure 5: A Strategic Triangle Approach to Pakistan’s Coronavirus Efforts

While Pakistan has “flattened the curve,” India faces dire public health and economic problems because of a public value failure. Framing it in public value terms, Indians could not count on civil society initiatives in the way that Pakistanis could, and there was a legitimate fear of starvation that led the public to flight towards the countryside. Public managerial coordination in Pakistan involved a centralized mechanism between the federation and provinces, and drew upon both civil and military resources. It also executed targeted ‘smart’ lockdowns to keep large-scale economic activity going while keeping hot zones confined. It also prevented rural transmission through active check points and rigid adherence to mobility restrictions.

In India, the lockdown of late March was announced a four hours’ notice, sending the public into disarray and leaving many stranded or seeking to flee a 3-week imposition. Gross mismanagement of funds, resources, and news-flow also occurred throughout the pandemic in India. The Indian politicians, for their part, sought to apply spin and denied the gravity of the situation, while the political leadership sought instead to strike a balance between “lives and livelihoods” while acknowledging the gravity of the situation.

All this said, however, in either the case of India or Pakistan, it is by any stretch of the imagination too early to declare a full victory in this fight against the virus. Covid-19 seems to be returning in new waves, and even in countries that considered the war over, new cases are appearing with frightening ferocity. For the big losers in the early phase of the war: US, Brazil, and India, there may be instructive lessons from the Pakistani context that may warrant attention. Yet this battle is, as of this writing, an ongoing one, and continued vigilance is required for a longer-term assurance of reprieve and for public value preservation.

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[1] It is also worth examining the importance of mosquito-vector pathogens such as Dengue (see Chohan 2019b)

[2] See discussion in a MoveHub compilation of three conservatism indices: https://worldpopulationreview.com/country-rankings/most-conservative-countries

[3] These issues have been covered extensively in recent CASS papers, see Chohan 2020b-l

[4] The horizon of analysis in this paper is confined to September 2020, to set it as the “early” phase of the coronavirus pandemic.

[5] It is worth reemphasizing that this analysis speaks only to the “early phase” of the pandemic and that subsequent events may lead to spikes or declines that were unforeseeable at the time of this writing. Of particular concern in this context is the re-opening of schools in both countries (after mid-September 2020), which posed a serious risk of triggering a new wave of coronavirus cases.

[6] Urdu: makhsoos bandisheinمخصوص بندشیں

 

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