Inequalities are pathological, and they are of epidemic proportions in Pakistan. Gender, class, ethnicity, educational status, religion and geographical location are some of the axes on which inequalities can be situated. It is tragic and infuriating to see the afflictions this epidemic of inequality embodied in gender-based violence, poverty, racial discrimination, ethnic conflict, forced evictions and communal hatred. These problems are deep-rooted in structures of inequality and injustice which have become all too obvious in times of Covid-19. There is a syndemic between the new coronavirus and social inequalities that have long plagued this country and are now amplifying.

Because of this co-morbidity of inequality, Covid-19 disproportionately affects those who are at the receiving end of inequalities, including women and girls, religious and ethnic minorities, rural and urban poor, people with non-normative sexual and gender identities, and those in precarious employment and irregular income. Urban populations in low-income areas or katchi abadis have suffered more severely due to their pre-existing problems of overcrowding and lack of civic amenities. Women are more exposed to risk of infection due to their role as primary caregivers for the sick and older people in multi-generational households under the prevalent gender norms. These norms also put them at a greater risk of gender-based violence under conditions of lockdown and economic hardships for poorer households. Related to economic hardship is the problem of food insecurity, especially for the urban poor. Covid-19 containment policies have intensified this problem for half of the male and 70 percent of the female workforce who subsist on daily wages or unpaid family work. Thus, the already vulnerable sections of population are not only at a greater risk of contracting the virus due to their inability to shield themselves, but are also at greater risk of losing their livelihoods and social protection due to a lack of adequate protection from the government.

The federal government responded with a new unconditional cash payment, administered through the flagship Ehsaas programme. However, this process leaves out very significant number of households that meet the eligibility criteria but do not receive transfers as well as very significant tranches of poor populations that are not categorised as poor as per the data-intensive ‘rule-based’ analytics methodology. The unconditional grants for the poor under the Ehsaas Emergency Cash programme could not be disbursed effectively due to the absence of local governments in three provinces. Given the limited proportion of the population coming under safety nets, the government has assumed that low-income households will simply draw upon kinship networks, yet this will pressure relations within the households and beyond. Stories we are hearing from the low-income neighbourhoods suggest that these pressures are resulting in family breakdown, violence and mental ill health. Low-income neighbourhoods are also settings where poor religious minorities have been notably stigmatised by the epidemic.

Covid-19 is compounding health inequalities due to the role of pre-existing chronic health conditions in exacerbating the severity of the disease and resulting debility. Medical care for acute health problems and child immunisation have yet to receive governmental attention. Pakistan’s public health system has been described as ‘choked pipes’ because its capacity is far overstretched. This already overstretched health system was not prepared to deal with a crisis of this magnitude.

Unlike past epidemics, such as HIV/AIDS, this epidemic did not arrive with internationally tried and tested templates for response. There were no established epidemiological target groups or intervention blueprints from other countries. This was due to the nature of the infection, which was initially described, erroneously, as a ‘great leveller’, not sparing anyone regardless of their wealth, health, piety or other personal attributes. The sheer pace of the spread of this novel virus was also startling, leaving very little to benefit from other countries’ experiences of dealing with it. In Pakistan, especially in the Punjab, the health sector was already dysfunctional due to the confrontation between health workforce and the government over the ongoing privatisation of public sector hospitals. We have now seen protests over the lack of PPE for healthcare professionals, and the contradictory stances taken by the federal and provincial governments, thus exacerbating the woes of those who could not afford private care. Meanwhile, as the Human Rights Commission of Pakistan has rightly highlighted in its recent report, Citizens-COVID19-Government: Pakistan’s response, traders and big businesses lobbied the government to obtain the lion’s share in Covid-related relief package in the form of concessions such as loan deferments and tax refunds, depriving the marginalised and vulnerable from direly-needed support. No ‘great leveller’, Covid-19 has proved to be a ‘great unequaliser’, not because of what is inherent to the disease but because of how the response to this crisis has been devised. Covid-19 has magnified our existing social inequalities and laid bare the structural conditions that lie behind them. This crisis presents us an urgent juncture to address structural problems at the root of this amplifying epidemic of inequality.

The writer is a lecturer in medical anthropology at the University of Edinburgh. He is the author of AIDS in Pakistan: Bureaucracy, Public Goods and NGOs. He can be reached at ayaz.qureshi@ed.ac.uk and on Twitter  @AyazAQureshi