The World Health Organisation has recommended that Pakistan impose a country-wide intermittent lockdown as the case notification has surpassed over 5,000 cases a day. Ground realities in terms of actual number of patients and the availability of ICU hospital beds and ventilators are not clear. Reports suggest that private hospitals, which cater to 70 percent of the population, are no longer accepting Covid-19 patients. The situation at public sector hospitals is bleak. It is claimed that there is still some unused capacity – but this maybe a political claim. Pakistan’s pandemic problem appears to be compounded by many factors including non-compliance with prescribed safety measures.

The indifference to precautions like wearing masks, maintaining social distance, and avoiding large gatherings is evident across the country. Do people understand what they need to do? Are they confused? Are they tired? Or do they think there is no threat?

There is no treatment for Covid-19 yet, nor is there a vaccine. The only way we can fight it is by acting to prevent transmission through non-pharmaceutical interventions (NPIs). These interventions, reserved for pandemics and aimed at reducing opportunities for exposure, include: (i) personal measures such as staying home when ill, covering coughs and sneezes, washing hands often, and social distancing; (ii) communitywide measures such as coordinated closures of child-care facilities and schools and cancellation of mass gatherings; and (iii) imposing lockdowns that prevent movement of people and hence the contagion.

In early March we were praised by the WHO for our rapid response to the pandemic – we were ready. Sadly, there was a lag in testing and effective contact tracing, and therefore a lockdown was imposed. Given the lack of compliance with NPIs, all the lockdown did was slow down the pandemic; when the lockdowns were relaxed, the virus had its chance.

NPIs help slow the spread and decrease the impact of a pandemic. This is, however, not as easy as one size fits all. Before developing NPI recommendations for a community we need to review the effectiveness of the intervention (compliance), the ease of implementation (including unwanted consequences), and the importance of the intervention as a public health strategy. These past months we needed to monitor the following carefully: what type and degree of NPI implementation was working; what was the level of compliance with NPI measures; and was there an emergence of intervention fatigue. Instead of focusing on the effectiveness of NPIs in mitigating the impact of the pandemic, the focus was the economic crisis.

It appears that 35 percent of all infections are occurring in men between 20 and 40 years of age. Apparently, this age group is not as compliant as others. This ties in with results of a survey conducted in the UK last month which found that young men are more likely than women to break lockdown rules.

Public awareness

We needed to promote public understanding and awareness, that individual action is essential for effective implementation of the NPIs, and crucial to its success. Within weeks, information about what precautions to take was being disseminated across TV channels, radio, social media and even by phone companies. The government was also prompt in establishing communication channels that enable the public to ask questions and express concerns, including call centres or social media sites, and an information portal with details of accumulating statistics on cases and deaths.

Cultural commitment

The adoption of health-protective behaviours depends on our beliefs about the risks we run when we do not comply. For people to comply, they need to believe that the risk of not doing so is high, especially with measures that demand a high degree of effort. So why is it that the public has not responded in the way it should have? Is this a social or cultural effect?

Political or health briefings from the beginning of the pandemic in Pakistan have mirrored uncertainty and lacked clarity.

People of Pakistan are strongly influenced by attitudes and beliefs in their adoption of health behaviour despite the risks to self, family, and community. Pictures from Ramazan and Eid suggest that it is socially acceptable for the masses to not wear masks and practice social distancing. This highlights the cultural commitment to community acceptability and social desirability over rational health seeking behaviour.

Trust and consistency

Trust in authorities influences how risk is perceived and this in turn can lead to an effect on compliance with health measures. A study from the 2009 swine flu pandemic found that having trust in authorities influenced people into complying with control measures such as quarantine and avoidance of crowds. Another key area the government must focus on is consistency. It has been shown theoretically that inconsistent information reduces trust levels over time, with people ultimately ignoring information altogether. In Toronto, during the SARS outbreak in 2003, inconsistent information from the Canadian authorities affected people’s compliance with quarantine measures. Political or health briefings from the beginning of the pandemic in Pakistan have mirrored uncertainty and lacked clarity.

Initial concern about the fate of those who tested positive – with patients posting videos that went viral – did not help. It was unfortunate and has contributed to reluctance by people to be tested for Covid-19 despite being symptomatic.

Transparency

Without disclosing it or following standard protocols, doctors and other healthcare practitioners are being forced to triage patients, due to lack of resources and planning. Random triaging poses serious risks to minority populations, like the elderly, handicapped and the transgender community, along with people from the lower socio-demographic background. Sadly, there are other hidden victims of the pandemic. This includes people seeking healthcare services for other morbidities, such as cancer or kidney diseases and those needing surgical intervention. In this way it is uncertain what the indirect health loss to the nation from the pandemic is. Marginalisation and lack of transparency both may have a significant role in non-compliance in the public.

Other reasons include illiteracy and low health literacy, adaptability to public health guidelines, poverty, joblessness, informal employment which relies on daily income, panic and fear about spread through media which confuses and compels people to cling to the ‘normal’ of the past, and dependency on superstitious beliefs that piety and faith can prevent susceptibility to the virus.

How do we make people care?

Once we understand that compliance drops because of a lowering of perceived risk, cultural commitment, and state and health sector policies, any strategy adopted hereon must recognise that we do not have the time to transform culture and structure to manage this pandemic.

Enforcing strict compliance and protective measures in the public through legislated punitive measures offers a way out. While there is great critique against panoptical surveillance and civilian constraints, the bigger problem for a poor country like Pakistan is that enforcing compliance in public requires consistent surveillance, a well-paid and trained taskforce, and a penalising mechanism. However, Pakistan does not have the resources or state commitment for this kind of implementation. In lieu of this, it may be argued that there does not seem to be any other solution to the management of this pandemic, unless the government reverts to a strict lockdown and enforced social distance.

On June 4, wearing masks in public was made mandatory. Social media has reported police officers using tasers on people not wearing masks – a rather severe tool to enforce compliance and one that can cause more harm to the individual and collective behaviour.

Lastly, an incomplete understanding of human behaviour has resulted in the implementation of ineffective control measures in Pakistan. We must learn and analyse this in more depth so that in future we do not adopt NPIs that take up valuable time and resources but have little-to-no impact on controlling the pandemic. For now, we need to ensure the risk is understood by everyone by being honest and transparent.

If a lockdown cannot be imposed then we need to do the following to tame this pandemic: stop worrying about the number of cases; focus on the number of deaths; protect vulnerable populations; be clear about what is needed from the public; enforce the wearing of face coverings in public; prohibit mass gatherings; encourage people to maintain physical distance and wash hands regularly if they can. We need to reassess, rethink and repeat.

Sara Rizvi Jafree is an assistant professor at the Forman Christian College in Lahore. Natasha Anwar is a consultant molecular biologist at the Aga Khan University Hospital regional lab in Lahore. The institutions may not necessarily subscribe to the views expressed by the authors