essay on corona pandemic in pakistan

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Peer-reviewed

Research Article

COVID-19 in Pakistan: A national analysis of five pandemic waves

Roles Conceptualization, Formal analysis, Investigation, Methodology, Software, Validation, Writing – original draft

Affiliation Research and Development Solutions, Islamabad, Pakistan

Roles Conceptualization, Data curation, Formal analysis, Methodology, Software, Validation, Writing – original draft

Roles Conceptualization, Data curation, Investigation, Methodology, Validation, Writing – original draft

Roles Conceptualization, Data curation, Supervision, Validation, Visualization, Writing – review & editing

Affiliations Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan

Roles Conceptualization, Investigation, Project administration, Supervision, Validation, Writing – review & editing

Affiliation Akhter Hameed Khan Foundation, Islamabad, Pakistan

Roles Conceptualization, Funding acquisition, Investigation, Project administration, Supervision, Validation, Writing – review & editing

* E-mail: [email protected]

Affiliations Research and Development Solutions, Islamabad, Pakistan, Ministry of National Health Services, Regulation and Coordination, Islamabad, Pakistan

• Taimoor Ahmad, 
• Mujahid Abdullah, 
• Abdul Mueed, 
• Faisal Sultan, 
• Ayesha Khan, 
• Adnan Ahmad Khan

• Published: December 29, 2023
• https://doi.org/10.1371/journal.pone.0281326
• Peer Review
• Reader Comments

The COVID-19 pandemic showed distinct waves where cases ebbed and flowed. While each country had slight, nuanced differences, lessons from each wave with country-specific details provides important lessons for prevention, understanding medical outcomes and the role of vaccines. This paper compares key characteristics from the five different COVID-19 waves in Pakistan.

Data was sourced from daily national situation reports (Sitreps) prepared by the National Emergency Operations Centre (NEOC) in Islamabad. We use specific criteria to define COVID-19 waves. The start of each COVID-19 wave is marked by the day of the lowest number of daily cases preceding a sustained increase, while the end is the day with the lowest number of cases following a 7-days decline, which should be lower than the 7 days following it. Key variables such as COVID-19 tests, cases, and deaths with their rates of change to the peak and then to the trough are used to draw descriptive comparisons. Additionally, a linear regression model estimates daily new COVID-19 deaths in Pakistan.

Pakistan saw five distinct waves, each of which displayed the typical topology of a complete infectious disease epidemic. The time from wave-start to peak became progressively shorter, and from wave-peak to trough, progressively longer. Each wave appears to also be getting shorter, except for wave 4, which lasted longer than wave 3. A one percent increase in vaccinations decreased deaths by 0.38% (95% CI: -0.67, -0.08) in wave 5 and the association is statistically significant.

Each wave displayed distinct characteristics that must be interpreted in the context of the level of response and the variant driving the epidemic. Key indicators suggest that COVID-19 preventive measures kept pace with the disease. Waves 1 and 2 were mainly about prevention and learning how to clinically manage patients. Vaccination started late during wave 3 and its impact on hospitalizations and deaths became visible in wave 5. The impact of highly virulent strains Alpha/B.1.1.7 and Delta/B.1.617.2 variants during wave 3 and milder but more infectious Omicron/B.1.1.529 during wave 5 are apparent.

Citation: Ahmad T, Abdullah M, Mueed A, Sultan F, Khan A, Khan AA (2023) COVID-19 in Pakistan: A national analysis of five pandemic waves. PLoS ONE 18(12): e0281326. https://doi.org/10.1371/journal.pone.0281326

Editor: Huzaifa Ahmad Cheema, King Edward Medical University, PAKISTAN

Received: January 20, 2023; Accepted: December 12, 2023; Published: December 29, 2023

Copyright: © 2023 Ahmad et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data was provided to the Akhter Hameed Khan Foundation (AHK-F) team for this study as part of its work with Pakistan’s Federal Ministry of National Health Services, Regulations & Coordination (MoNHSR&C) and the National Command & Operation Centre (NCOC) in Islamabad, which are leading Pakistan’s response to the COVID-19 pandemic. The AHK-F team has provided analytical support to the above entities, and such created knowledge that has directly informed pandemic policy-making in Pakistan. COVID-19 data is compiled and shared in daily National Situation Reports, or Sitreps, by the National Emergency Operation Centre (NEOC). Each day’s Sitrep is compiled as a PDF file. The data used for this study was manually compiled from these PDF files and then used in STATA. The parentage of this data is with the NCOC and the MoNHSR&C. The AHK-F team received this data with the express understanding that it would be kept confidential. However, the data can be obtained independently from the NEOC, through a data request procedure, which is subject to approval from the MoNHSR&C. The data request itself is to be addressed to: Dr. Shahzad Baig, National Coordinator, National Emergency & Operation Center, D Block, EPI Building, Chak Shahzad, Park Road, Islamabad. Email: [email protected] Phone: +92-51-8730879. The data on Oxford Health and Containment Index is taken from and publicly available at the following GitHub repository: https://github.com/OxCGRT/covid-policy-tracker/tree/master/data .

Funding: This work was supported, in whole or in part, by the Bill & Melinda Gates Foundation [grant number: INV-025171]. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

In Pakistan, the first case of COVID-19, a novel and little-understood disease, was detected on February 26, 2020. Being a developing country with limited resources, crumbling health infrastructure and low health expenditure [ 1 ], Pakistan has no past experience with pandemics and a high burden of communicable diseases [ 2 ]. As of February 23, 2022, the country had fully vaccinated 43% of its total population [ 3 ] and the Omicron variant of COVID-19 was the dominant strain [ 4 ]. These factors make Pakistan a high-risk country, with a large pool of infection-susceptible people.

The emergence of COVID-19 has arguably been the biggest social and economic disruption in Pakistan in recent history. The pandemic has largely manifested itself in five distinct waves each of which have a rise, plateau, and trough in cases, followed by a period of dormancy, after which the incidence of COVID-19 infections begins to rise again. Thus, each individual wave follows a four-stage pattern followed by endemicity that has been seen for many infectious disease epidemics [ 5 ]. Beyond anecdotal observation, there is evidence that this is happening with COVID-19 as well [ 6 ]. What sets COVID-19 apart is that after completion of an individual wave, a new one would come along shortly, rather than taking much long, for example, annual recurrences for influenza. This pattern has been seen across the globe [ 7 – 11 ] with the timing of COVID-19 waves in different countries broadly coinciding [ 6 ].

In this context, current literature on COVID-19 largely focuses on high-income countries during the initial waves [ 7 , 12 , 13 ], or aggregated at regional levels [ 8 , 14 ]. Given the different capacities of countries to manage the pandemic [ 15 ], there is a need to explore the characteristics of the subsequent pandemic waves in a developing country context, preferably with granularity of a country-level analysis.

This paper aims to offer a comprehensive understanding of the impact of COVID-19 in Pakistan. To achieve this, we examine the five waves of the pandemic in Pakistan, analyzing various key aspects and critical statistics. These include the total number of COVID-19 tests conducted, confirmed cases, hospitalizations, COVID-19-related deaths, and the progress of vaccinations during each wave. Additionally, we employ statistical modeling to identify the significant factors contributing to COVID-19-related deaths. Our goal is to fill the existing gap in the literature by providing valuable insights specific to a developing country like Pakistan, where limited evidence currently exists.

Criteria for COVID-19 waves

We begin by retrospectively defining various time periods between 2020 and 2022 as distinct waves, based on existing literature [ 16 ]. There are a total of 628 observations (daily set of indicators) across these five waves. Based on our criteria, the starting point of each COVID-19 wave is defined as the day with the lowest number of daily new COVID-19 cases preceding a consistent rise in these cases, before the peak of the respective COVID-19 waves. The end of each wave is defined as the day with lowest number of daily new COVID-19 cases following a 7-day decline; this number also needed to be lower than the cases on any of the 7 days that followed it ( Table 2 ).

Data and variables

In order to estimate the pattern for COVID-19 throughout the five waves in Pakistan, we use time series data of various daily indicators from April 3, 2020 to February 23, 2022, which are categorized into the following broad themes:

• i) Wave timespan
• ii) COVID-19 tests
• iii) COVID-19 cases
• iv) Test-to-case ratio
• v) COVID-19 positivity
• vi) Hospitalization and treatment
• vii) COVID-19 deaths
• viii) COVID-19 vaccination
• ix) Policy environment

Several variables in the list above were transformed into ratios for the purpose of describing all five COVID-19 waves in Pakistan ( S1 Table ).

The data for all but two of the above themes, COVID-19 vaccination and policy environment, is compiled from daily national situation reports (Sitreps). These Sitreps are prepared by the National Emergency Operations Centre (NEOC) in Islamabad, Pakistan. Data in these Sitreps have served as the basis for all major COVID-19 policy decisions in Pakistan.

The data for COVID-19 vaccination is sourced directly from the National Command & Operation Centre (NCOC), Islamabad, Pakistan, which is the government forum that brings together the ministries of Health and Planning along with the military to determine pandemic policy and to coordinate the response. Data for the policy environment is taken from a publicly available dataset from the University of Oxford’s Blavatnik School of Governance [ 17 ]. This dataset is compiled by using qualitative information about the non-pharmaceutical interventions (NPIs) in a country and quantifying them into an index called Oxford Containment and Health Index for COVID-19. A detailed methodology of the index calculation can be found in a working paper by the Blavatnik school [ 18 ].

Model specification

Apart from presenting statistics on daily indicators for every wave, we estimate the predictors of daily new deaths due to COVID-19. For our model of daily new COVID-19 deaths, we use a linear ordinary least square (OLS) regression. The data as well as the model is divided into five distinct periods, representing the five waves of COVID-19 in Pakistan, as of February 2022. The manuscript comprises statistical analysis and inferences for each of the five waves separately.

Our independent variables measured at daily intervals are:

• i) Log of daily new COVID-19 cases with 21-day delay ( LnX1 t+21 );
• ii) Log of daily new COVID-19 tests with 28-day delay ( LnX2 t+28 );
• iii) The Oxford containment and health index for COVID-19 with 14-day delay ( X3 t+14 );
• iv) Time variable capturing the time trend ( X4 t );
• v) The number of people on ventilators as a proportion of the total admitted ( X5 t );
• vi) The number of people on oxygen as a portion of the total admitted ( X6 t );
• vii) Log of second doses of COVID-19 vaccines administered with 14-day delay ( LnX7 t+14 )

Daily new COVID-19 cases are regressed with a 21-day lag, since among those who die from COVID-19 infection, death occurs between a median of 14 days [ 19 ] and 25 days (average of three weeks) after presenting symptoms [ 20 , 21 ]. This is pertinent in the case of Pakistan, as most of the COVID-19 testing in the country has been symptomatic, i.e., done when someone develops symptoms of COVID-19 and hence either voluntarily gets tested or is prescribed by a medical professional to do so.

Given the delay for daily new cases, daily new COVID-19 tests are regressed with a delay of 28 days. This delay allows for the time it takes for someone to test positive for COVID-19 and for their symptoms to worsen (for example, by escalating to hospitalization, which takes nearly a week [ 22 ] before resulting in death). For vaccination, a 14-day lag is taken, as immunity from vaccines is generally understood to develop two weeks or longer after receiving a shot [ 23 – 25 ].

The Oxford Containment and Health Index is calculated out of 100 where 100 means strict restrictions and 0 means no restrictions imposed on the general population. This variable is regressed with a 14-day lag, as we assume that any new government restrictions will take approximately that long to have any effect. Additionally, the time variable is meant to capture any unmeasured or seasonal effects on COVID-19 deaths in Pakistan, such as an overall rate of increase or decrease of daily deaths in each wave. We assume the error term is not correlated with any of the independent variables.

Newey-West standard errors are used to account for autocorrelation and potential heteroskedasticity in the error terms. Statistical tests are performed to ensure that the required assumptions for the regression model are met: for heteroskedasticity, the Breusch-Pagan test is applied, whereas for serial correlation, the Durbin-Watson test is used. Variance inflation factor (VIF) is calculated for multicollinearity. The presence of unit roots is tested using augmented Dicky-Fuller tests for each independent variable in our regression model. All the variables are found to be stationary, fulfilling an important pre-requisite for our analysis ( Table 1 ). The statistical analysis is carried out using STATA 17 software.

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https://doi.org/10.1371/journal.pone.0281326.t001

Summary statistics

Pakistan experienced five distinct waves from 3 rd April 2020 till 23 rd February 2022 ( Fig 1 ). Wave 1 lasted the longest (150 days), while the wave 5 was the shortest (83 days). Wave 4 was remarkable for its relatively rapid upslope and a long tail, while wave 5 showed a reverse pattern. The duration of each wave of COVID-19 in Pakistan was shorter than the preceding one apart from wave 4. After wave 1, each wave took less time to reach its peak and took longer to reach its trough, apart from wave 5.

https://doi.org/10.1371/journal.pone.0281326.g001

The capacity to conduct tests expanded over time from an average of 17,142 tests daily during wave 1 to 49,650 during wave 5. The increase in the daily tests peaked during wave 4. The highest average daily number of cases (3147) were observed during wave 3. The rate of increase of COVID-19 cases was the highest during wave 4, but the rate of decline in cases after the peak of a wave was the fastest during wave 5. Test-to-case ratio kept increasing from 15 during wave 1 to 57 during the wave 5. While total positivity varied across waves, the rate in daily change of positivity remained relatively unchanged apart from waves 2 and 3, where it was lower as compared to other waves ( Table 2 ).

https://doi.org/10.1371/journal.pone.0281326.t002

Hospitalizations were the highest for waves 1 and 3 and the lowest for wave 5, whereas duration of hospitalization fell linearly from an initial 13 days during wave 2 to 5 days during wave 5. Hospitalizations became more specific over time in that, nearly two thirds of admitted patients during wave 1 were stable, compared to 9% during wave 5. The average stable-admitted ratio decreased continuously from wave 1 to wave 4 but increased slightly in wave 5. The rate at which people recovered from COVID-19 and/or were discharged from hospital was the fastest in wave 4 but the slowest in wave 2.

The average oxygen beds-admitted ratio continuously increased in each wave, reaching its maximum value in wave 4. During wave 1, 27% of all admissions required oxygen and 7% needed a ventilator, compared to 81% and 10% respectively during wave 5. The average oxygen bed utilization followed a declining trend except for wave 3 (24%) and was the lowest in wave 5 (7%). The trend of average ventilators utilization ratio showed that all available ventilators were not fully utilized in any of the five waves. The highest ventilators utilization was in wave 3 (20%) and the lowest in wave 5 (5%). These two ratios suggest that most critical patients were put on oxygen for recovery and a small proportion of these people were transferred to ventilators.

Deaths from COVID-19 were the highest during wave 3 at 9,423, which also saw the highest daily number of deaths (78.5) and the highest rate of increase in daily deaths. Average daily deaths to hospitalization rate peaked during wave 2, while deaths to ventilator use was the highest during wave 1. Average deaths to case ratio was the highest for wave 3 but was in the 2.2–2.8% range, except for wave 5 when it was 1.1%.

Pakistan’s vaccination drive started towards the end of wave 2, but full vaccination (i.e., people receiving both their doses) did not happen until the beginning of wave 3. Consequently, total and daily new second dose of vaccine administered was highest in wave 5. Government restrictions, measured by the Oxford Containment and Health Index, appeared to be comparable in each wave.

OLS regression results

The linear OLS regression results for daily new COVID-19 deaths indicate that daily new COVID-19 cases were a statistically significant determinant for daily new deaths in all five waves at 95% CI; a one-percentage increase in COVID-19 cases caused a 0.46–0.69% increase in deaths across the five waves ( Table 3 ).

https://doi.org/10.1371/journal.pone.0281326.t003

The daily new COVID-19 tests and Oxford containment and health index, which records the presence of government NPIs and restrictions, were both found to be statistically significant determinants of COVID-19 deaths in wave 1. Increasing daily new tests by 1% reduced daily deaths by 0.65% (95% CI: 0.26, 1.04). An increase in Oxford Containment and Health Index by 1 point resulted in 0.03% reduction in daily new deaths (95% CI: -0.05, -0.005).

The time trend variable was statistically significant in waves 1, 3 and 4. The coefficients indicate that, on average, daily COVID-19 deaths decreased at a rate of 0.04% per day (95% CI: -0.04, -0.03) during wave 1. However, daily new deaths reduced at a rate of 0.01% per day during wave 3 (95% CI: -0.02, 0.002) and wave 4 (95% CI: -0.01, 0.00).

The ventilator-admitted ratio was statistically significant in waves 1, 4 and 5. The coefficient was negative throughout these three waves and significant at 95% CI. The coefficients indicates that if ratio of patients on ventilator out of the admitted increased then daily new deaths would decrease by 14–17%.

Oxygen-admitted ratio was only significant in waves 1 and 2 at 95% CI, where the coefficient was positive, implying that an increase in the ratio of oxygenated patients out of the total admitted increased was associated with an increase in daily new deaths due to COVID-19 by approximately 4%.

Lastly, the number of fully vaccinated people is statistically significant in each of the last three waves. During wave 3, COVID-19 deaths increased by 0.07% (95% CI: 0.006,0.14) as percentage of fully vaccinated people increased by one percent. This rate increased to 0.10% (95% CI: 0.006,0.14) during wave 4. However, during wave 5, daily new deaths due to COVID-19 decreased by 0.38% (95% CI: -0.67, -0.08) as fully vaccinated people increased.

Pakistan experienced 5 distinct waves from 3 rd April 2020 to 23 rd February 2022. Our analysis reflects both the evolution of Pakistan’s response, as well as the differential impact of different variants of the virus shaped the contours and features of each wave. Pakistan experienced its initial wave earlier than other South Asian countries including India, Bangladesh, Sri Lanka and Nepal, while peaks for the subsequent waves coincided with those in other countries [ 26 ].

The upslope, as seen by the rate of change for testing and cases, was always steeper than during the downward slope of a wave. This pattern follows what is known about infectious epidemics in that cases rise quickly, plateau and then fall, slowly to an endemic state where a low ebb of infections persists in the community indefinitely [ 5 ]. In fact, each wave behaved as a typical epidemic caused by a distinct variant of the virus. Wave 1 was dominated by B.1 variant, wave 2 by B.1.36 variant, the wave 3 by Alpha/B1.1.7 and Delta/B.1.617.2 variants, wave 4 had majority cases of the Delta/B.1.617.2 variant [ 27 – 29 ] while wave 5 was driven by Omicron/BA.5.2.1.7 [ 4 ].

A key challenge faced by Pakistan at the beginning of the pandemic was that there was little prior experience with any pandemic outbreak of such level. Although disease surveillance systems exist, they had not been scaled to manage case surveillance, hospital admissions, daily deaths, and eventually large-scale adult vaccination and event tracking. Pakistan has a federal system of governance where provinces provide health services while the federal ministry provides guidance and coordination. In addition, considerable curative care is in the private sector. To address the potential difficulties in mounting a unified national response to the disease in the face of this diversity, a National Action Plan for COVID-19 was formulated in March 2020 that placed the responsibility for the national response in a National Coordination Committee (NCC) that was headed by the Prime Minister and attended by all federal ministers. The NCC set national policy which was implemented by the National Command and Operation Centre (NCOC) that was co-headed by the military and civilian leadership [ 30 ]. The NCOC coordinated the management of the extensive lockdowns, other key NPIs such as school closures, limited opening hours for essential businesses (examples of which included grocery stores and pharmacies), closure of borders, cancellation of public events and social gatherings [ 31 , 32 ]. This was supported based on an elaborate data gathering and analysis system that guided daily decisions.

Wave 1 continued the longest and intervals became shorter between each successive wave. Each wave showed unique features, that were determined by the particular variant that drove that wave, along with the larger context that included the type of the variant driving the wave, the extent and type of preventive interventions and eventually the availability of the vaccine.

Pakistan’s response to COVID-19 evolved over time. For example, wave 1 had the highest positivity rates and the longest duration, in part due to low initial rates of testing, including very little contact tracing in the early days [ 33 ]. As testing increased and mobility restrictions tightened, duration of waves 2 and 3 became shorter. However, by the end of wave 2, intervention fatigue had set in. Implementation was laxer, and these factors contributed to more cases and deaths of any wave during wave 3. Indeed, the Oxford Containment and Health Index was significant only during wave 1 in terms of preventing deaths.

In addition to preventive measures, the higher daily COVID-19 cases in waves 3, 4, and 5 may be attributed to highly transmissible Alpha [ 34 , 35 ], Delta [ 36 , 37 ] and Omicron [ 38 ] variants, and to easing of severe restrictions such as lockdowns and school closures [ 39 ]. It is also possible that many cases were missed during wave 1 due to limited testing. However, the stability of daily testing in waves 3 to 5 suggests a stable equilibrium between the testing system and how cases were being incident–the system was capturing most of the cases from previously recognized populations and locations. It is likely that undiagnosed cases and deaths were few, since as part of the national surveillance, teams kept abreast of burials in large and midsized towns and also periodically canvased opinion of general practitioners about upsurges in respiratory illnesses. On average, Pakistan had fewer cases per million population than neighboring countries of India, Bangladesh, and Iran, as well as several of the developed countries [ 26 ].

As with prevention, clinical management of cases evolved over time. Initially most cases were hospitalized as seen by the high case to hospitalization ratio–only 27% of admissions required oxygen 7% required ventilators during wave 1. In fact, there was a correlation between deaths and oxygenation (which was mostly at hospitals) during waves 1 and 2, a pattern that was seen globally. However, with each succeeding wave, use of oxygen increased while ventilators fluctuated within a narrow range, as was also seen in India [ 40 , 41 ]. Thus, even as COVID-19 hospitalizations peaked during wave 3, hospitalization to case ratio increased, and average duration of hospitalization and the use of hospitals for simple oxygenation fell, suggesting hospitals, ICU and ventilators, were increasingly reserved only for the sickest [ 42 ]. Deaths correlated best with a 21-day delay model rather than a 28-day one, suggesting that most deaths happened early after infection. Higher hospitalizations during wave 3 may also have been attributed to the Alpha followed by Delta variants [ 43 – 45 ]. By contrast, lower hospitalizations, length of stay, and mortality during wave 5 may be attributed to the Omicron variant that was seen worldwide [ 46 , 47 ], and specifically in South Africa [ 48 ] and Brazil [ 49 ] during the Omicron waves. Vaccination started earlier on in wave 3 and more than half of the eligible population was fully vaccinated by wave 5 [ 3 ] and may have contributed to lower hospitalizations in wave 5. Unlike COVID-19 induced major challenges to the healthcare capacity in various countries [ 50 , 51 ], Pakistan was able to build healthcare resources capacity to keep pace with the pandemic. Ventilator and oxygen utilization never exceeded 20% and 24% respectively in wave 3.

Vaccination drive started in Pakistan by the end of February 2021. Despite a slow start, vaccination picked up pace from 26,356 daily vaccinations in wave 3 to 308,129 in wave 4 as it was rolled-out to younger population and vaccine supply increased in the country. Average daily deaths did not reduce significantly due to vaccinations during waves 3 and 4 [ 52 , 53 ], but showed marked reduction in hospitalizations and deaths towards the end of wave 4 and during the entire wave 5 [ 54 ].

From our regression model, we found that daily new COVID-19 cases were statistically significant determinants of daily new deaths due to COVID-19. The association was also observed from the wave 3 as both cumulative cases and deaths were the highest, including the average daily deaths which were considerably higher than any other wave, as seen in other countries [ 55 ]. Secondly, daily new deaths due to COVID-19 increased with patients on oxygenated beds while decreased with patients on ventilators in the initial waves, potentially due to high patients load in hospitals, critical patients were put on oxygen rather than ventilator. Wave 5 experienced the smallest number of daily COVID-19 deaths possibly because it was dominated by the Omicron variant [ 56 ].

Limitations

There are several limitations associated with the data used in this paper. While the official data used for the analysis are disaggregated by sub-national level, demographic disaggregation, such as age or gender, are not available. This limits the analysis in terms of the implication of gender and age on COVID-19 deaths. The national data is compiled by aggregating the numbers for each subnational unit in Pakistan. However, such an analysis would be too extensive to depict and therefore our analysis does not account for subnational differences. It is possible that distinctive cultures, behaviors, and differences in the stringency in enforcement of interventions vary between regions and may in theory, influence the number of COVID-19 cases and deaths.

Similarly, data for hospitalizations is also unaccompanied by any information on comorbidities, as this information was not available beyond treating hospitals, losing a level of richness of analysis that includes such comorbidities. Also, data for daily new hospital admissions started becoming available towards the very end of wave 1. Consequently, the average length of hospital stay could not be calculated for this wave.

The official vaccination data available to us at the time of this analysis is not desegregated by the different types of available vaccines, for example Sinopharm, CanSino, Sputnik V and others. Differential impact of each vaccine on COVID-19 deaths in Pakistan would be informative. All the above limitations notwithstanding, we are confident that this study provides crucial insights into the prevailing trends of COVID-19 in Pakistan in manner that is constructive.

We describe how COVID-19 waves differed in terms of cases, hospitalizations, and deaths in Pakistan, and analyze potential reasons for these differences. Pakistan experienced its initial COVID-19 wave earlier than other South Asian countries, with wave 1 lasting the longest. As testing increased and restrictions were enforced, subsequent waves became shorter, but wave 3 stood out due to lax implementation, resulting in the highest number of cases and deaths. The higher daily cases in waves 3, 4, and 5 were also attributed to the highly infectious Delta and Omicron variants. Wave 3 recorded the most COVID-19 deaths, with 9,423 fatalities, the highest daily death rate, and the steepest increase in daily deaths. Lastly, vaccination began in wave 2, with full vaccination achieved in wave 3, and the highest second-dose vaccinations occurred in wave 5.

At the pandemic’s onset, Pakistan’s lack of prior experience was a challenge. However, a National Action Plan for COVID-19 was established in March 2020. COVID-19 management in Pakistan kept pace with the spread of the disease during five distinct waves and successfully implemented the COVID-19 vaccination drive nationwide. The experiences and limitations offer valuable insights for future pandemic management for a developing country like Pakistan.

Supporting information

S1 table. calculated ratio variables and their descriptions..

https://doi.org/10.1371/journal.pone.0281326.s001

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COVID-19 pandemic

Covid-19 pandemic response.

Humanity needs leadership and solidarity to defeat the coronavirus

The coronavirus COVID-19 pandemic is the defining global health crisis of our time and the greatest challenge we have faced since World War Two. Since its emergence in Asia late last year, the virus has spread to  every continent  except Antarctica. Cases are rising daily in Africa the Americas, and Europe.

Countries are racing to slow the spread of the disease by testing and treating patients, carrying out contact tracing, limiting travel, quarantining citizens, and cancelling large gatherings such as sporting events, concerts, and schools.

The pandemic is moving like a wave—one that may yet crash on those least able to cope.

But COVID-19 is much more than a health crisis. By stressing every one of the countries it touches, it has the potential to create devastating social, economic and political crises that will leave deep scars.

We are in uncharted territory. Many of our communities are unrecognizable from even a week ago. Dozens of the world’s greatest cities are deserted as people stay indoors, either by choice or by government order. Across the world, shops, theatres, restaurants and bars are closing.

Every day, people are losing jobs and income, with no way of knowing when normality will return. Small island nations, heavily dependent on tourism, have empty hotels and deserted beaches. The International Labour Organization estimates that 25 million jobs could be lost.

UNDP response

Every country needs to act immediately to prepare, respond, and recover. The UN system will support countries through each stage, with a focus on the most vulnerable.

Drawing on our experience with other outbreaks such as Ebola, HIV, SARS, TB and malaria, as well as our long history of working with the private and public sector , UNDP will help countries to urgently and effectively respond to COVID-19 as part of its mission to eradicate poverty, reduce inequalities and build resilience to crises and shocks.

“We are already hard at work, together with our UN family and other partners, on three immediate priorities : supporting the health response including the procurement and supply of essential health products, under WHO’s leadership, strengthening crisis management and response, and addressing critical social and economic impacts.” UNDP Administrator, Achim Steiner

Responding with people at the centre

Pakistan has witnessed a massive increase in its confirmed cases from the initial two confirmed on 26th February 2020. As a country whose economy is highly reliant on manufacturing and service industries, shutdown measures and disruptions in supply chains will negatively impact on the economy and society, particularly the poor. 

As in other countries, the pandemic is likely to stress the capacity of the public health system and result in loss of human lives.  Severe repercussions on livelihoods, especially of the most vulnerable, dependent on government support, are expected.  The shutdown measures have already impacted small businesses, small and medium enterprises and daily wagers associated with various sectors of the economy. Considering that the informal sector in the country accounts for a major share of the national economy[1] and employs 27.3 million individuals, an increase in un(der)employment and poverty coupled with implications on food production and overall food security are anticipated.

The Government of Pakistan is concerned with the social and economic implications of COVID-19 and has established, with the help of UNDP, a COVID-19 Secretariat in the Planning Commission to prepare a coordinated economic and social response and design evidence-informed interventions. The Secretariat is required to ensure adequate coordination between Federal and Provincial Governments, with UN and Development Partners.  

In this regard, the federal government as well as provincial government of Khyber Pakhtunkhwa have requested UNDP’s support on a range of areas including coordination, strategic communications, crisis management, business continuity and digital solutions to manage government response to the pandemic. Assistance with procurement of medical supplies and equipment is also being discussed.

Against this background, UNDP is currently in the following activities in response to COVID-19 in Pakistan.  (This page will be updated regularly.)

Supporting the Federal Government in coordination and strategic communications:

• Supporting the Planning Commission in establishing a Secretariat for coordinating socio-economic impact of COVID-19;
• Supporting the Federal Government and Khyber Pakhtunkhwa Government with Strategic Communications and Awareness;
• Supporting Economic Affairs Division to design ODA coordination system (aid effectiveness).

Supporting Ministry of Health and Khyber Pakhtunkhwa Government in health system response:

• Capacity support in crisis management and provision of digital solutions to enable business continuity;
• Supporting Khyber Pakhtunkhwa Government to enhance supply chain management (including procurement of health supplies and equipment).

Coordination of UN socio-economic impact needs assessment to identify mitigation responses:

• Impact assessment on the most vulnerable, policy recommendations & proposed programme interventions, to feed into the national action plan for COVID-19.

[1] The figure ranges from 18.2% to 71% based on different analysis 

While we do this, we must also consider ways to prevent a similar pandemic recurring. In the longer term, UNDP will look at ways to help countries to better prevent and manage such crises and ensure that the world makes full use of what we will learn from this one.

A global response now is an investment in our future.

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• Early Missteps
• Pandemic Policy in Pakistan’s Fractured Polity
• Mixed Messaging and the Power of the Pulpit
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• Health Systems in a Pandemic

Pakistan’s COVID-19 Crisis

A federal government misstep – lifting a lockdown too soon – has placed Pakistan among the twelve countries hardest hit by coronavirus. Nor has the economy recovered as intended. Authorities should let provinces make more health decisions and focus on helping citizens in need.

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What’s new?  Hoping to mitigate COVID-19’s economic toll, Imran Khan’s Pakistan Tehreek-e-Insaf government lifted a countrywide lockdown in May, leading to a spike in cases. August could see another surge since the public, misled by the clergy and mixed messaging from the government itself, may disregard precautions during religious festivities and ceremonies.

Why does it matter?  Climbing infection rates could overwhelm ill-equipped health systems and hinder economic recovery. If citizens are denied health care or adequate aid as the economy contracts, public anger is likely to mount, potentially threatening social order. Militants could take advantage, as they have in the past.

What should be done?  The federal government should guide provinces on pandemic policy and help reinforce their health systems but also permit them to devise their own local strategies guided by medical experts. It should work with the parliamentary opposition on its response, particularly on providing a safety net to vulnerable parts of society.

I. Overview

On 9 May, the Pakistan Tehreek-e-Insaf government almost completely lifted a nationwide lockdown it had imposed in late March to counter COVID-19. Pakistan subsequently saw a surge in cases, placing it among the top twelve pandemic-affected countries worldwide. The government justifies the easing of nationwide restrictions on economic grounds; indeed, the lockdown’s toll on the most vulnerable, workers and the poor has been brutal. Yet signs of economic recovery since it was lifted are few, while the virus threatens to overwhelm ill-equipped and under-funded health systems. Rising anger and alienation among citizens could threaten social order, potentially giving militants an opening to gain support. The federal government should revise its approach. It should seek consensus with political rivals on its coronavirus strategy, pay greater heed to public health experts, if feasible step up aid to families unable to get by and give the provinces more leeway to lead local efforts to deal with the public health crisis.

The government’s mixed messaging and misinformation from some religious leaders mean that many Pakistanis disregard public health advice. Prime Minister Imran Khan’s initial downplaying of the pandemic’s health risks led to widespread public disregard for social distancing procedures. The removal of restrictions on communal prayers in mosques also increased the risks of new virus clusters. Many clerics advocate religious practices that undercut physical distancing and other preventive measures; they tell worshippers that piety alone, and not health practices, will determine their fate. The federal government’s easing of lockdown measures, despite warnings by the political opposition and medical professionals that transmissions would surge, and the further lifting of the lockdown, on 9 May, encouraged public complacency. Though the government now urges people to respect social distancing rules, these calls are largely ignored. Many believe that the pandemic is over.

The federal government’s adoption of what it calls a “smart lockdowns” strategy may not be enough. The strategy entails removing restrictions in specific areas within cities or regions where the authorities assess that case rates are relatively low and imposing them where they are high. But poor data and low testing rates have hampered efforts to “track, trace and quarantine”, which involve identifying and isolating virus carriers and their contacts and placing hot-spots under quarantine, and are essential to curbing the virus. With COVID-19 spreading in densely populated cities such as Karachi, Lahore and Peshawar, limited closures are unlikely to prevent contagion. While city hospitals are better prepared to deal with the pandemic than some weeks ago, they could again be overwhelmed should cases surge in August, particularly if citizens ignore precautions during Eidul Azha celebrations and the month of Muharram, when large mourning processions are held. The virus has also spread to rural regions, where the health infrastructure is even weaker.

The federal government’s centralised decision-making has often made things worse. It has refused to share authority, even though the constitution grants the provinces responsibility for the health sector. Islamabad’s pandemic policies, devised by the top political and military leadership, have prevailed over provincial preferences, with court rulings strengthening centralised control. The Pakistan Peoples Party’s government in Sindh, the sole opposition-led province, has promoted rigorous restrictions, for instance, but has been unable to implement them in the face of Islamabad’s resistance. The federal government has also been reluctant to work with parliament or main opposition parties to forge a united response. The acrimony is rooted in contested mid-2018 elections, though the opposition has repeatedly offered to assist the government in containing the pandemic.

The public health crisis and economic downturn could be devastating, particularly if people feel it is mismanaged. Anger at the government and social tensions will mount if citizens sense that the government is not adequately looking after their health and wellbeing. In the past, militant groups have exploited such opportunities to gain local support.

While COVID-19 leaves Pakistan’s government few good options, some steps could minimise harm to lives and livelihoods. The prime minister’s fears about the toll of lockdowns are well justified. Yet the economy is unlikely to start moving unless the authorities can keep the virus at bay. Adapting the smart lockdown strategy might avoid the pain of a prolonged lockdown while still saving lives. This could mean allowing provinces, if medical experts so advise, to lock down entire cities and urban districts for short periods, instead of limiting them to partial closures. More broadly, the government should guide the country’s response but give provinces leeway to devise policies tailored to local needs. Bolstering the provinces’ health capacity – particularly testing – should remain a top priority. Emergency assistance to families that fall under the poverty line and unemployed workers remains critical. Prime Minister Imran Khan’s – and the country’s – interests would also be best served by working with the opposition to forge consensus on managing the consequences of an unprecedented and potentially destabilising health crisis.

II. Responding to the Pandemic

A. early missteps.

As happened in many other countries, early missteps overshadowed the Pakistan Tehreek-e-Insaf government’s response. In February, the government refused to repatriate hundreds of Pakistani students in Wuhan, China, fearing they would spread the virus. In itself, the decision appears to have been sensible, though perhaps the government could have brought them home but quarantined them. Yet despite its caution with citizens in Wuhan, it failed to properly screen inbound travellers, many of whom carried the virus. [fn] International flights continued to operate until 21 March. Hide Footnote  The first confirmed COVID-19 case in Pakistan was that of a Karachi student returning from pilgrimage in Iran on 26 February. Shia pilgrims coming home from Iran, at the time the region’s worst-hit country, formed the first major cluster of imported infections. The government quarantined hundreds of pilgrims in overcrowded, unhygienic conditions near the Iranian border but then allowed them to leave for their home provinces without adequate testing or isolation, spreading the virus throughout the country. [fn] Between 28 February and 15 April, 7,000 pilgrims returned from Iran, 6,800 through the Taftan border crossing, where many were initially quarantined. “7,000 pilgrims have returned from Iran since February: FO”, Dawn, 19 April 2020. Hide Footnote

The first major cluster of locally transmitted infections occurred when the ruling party’s Punjab government delayed a decision to cancel the Sunni proselytising group Tableeghi Jamaat’s major annual congregation ( ijtema ), due to take place for five days from 11 March. The organisers ultimately cancelled the ijtema , but only on 12 March, by which time an estimated 100,000 believers, including around 3,000 foreigners, had already set up camp together in close quarters. Had the Punjab government given “clear instructions”, a Tableeghi Jamaat follower said, “the event would not have happened”. [fn] The Punjab police put numbers at 70,000 to 80,000. Other estimates were as high as 250,000. Asif Chaudhry, “Tableeghi Jamaat in hot water in Pakistan too for Covid-19 spread”, Dawn , 8 April 2020. Hide Footnote  After its cancellation, most participants left, but a few hundred stayed on at the organisation’s Raiwind headquarters. They, too, were allowed to leave for their home provinces without being tested or isolated; Tableeghi Jamaat members also went on preaching missions throughout the country. Large clusters of virus transmission in at least two provinces, Punjab and Sindh, have been traced to Tableeghi Jamaat members who had participated in the Raiwind ijtema . [fn] “Limiting the spread,” Dawn, 2 April 2020; “27 per cent of Pakistan’s Covid-19 cases linked to Raiwind Ijtema : report”, The Express Tribune , 23 April 2020. Hide Footnote

B. Pandemic Policy in Pakistan’s Fractured Polity

The Pakistan Tehreek-e-Insaf government was slow to respond as the pandemic spread. The first cabinet meeting devoted to the subject was held on 13 March, weeks after the confirmed case in Karachi. [fn] “Pakistan closes western borders, bans public gatherings as coronavirus cases rise to 28”, Dawn , 13 March 2020. Hide Footnote  The federal government’s approach was then shaped by an adversarial relationship with the opposition and an overreliance on the military’s support.

At a time when political consensus was most needed in forging a national response to the pandemic, the federal government’s relationship with the two largest opposition parties, Nawaz Sharif’s Pakistan Muslim League and Bilawal Bhutto Zardari’s Pakistan Peoples Party, was strained. The antagonism had its roots in the contested July 2018 elections. Both main opposition parties attributed Imran Khan’s victory to manipulation. After forming a government with a razor-thin majority, and entering into coalitions with smaller parties, Imran Khan’s survival tactics have been twofold: to consolidate ties with the country’s powerful military, and to weaken opposition parties by targeting their top leaders, including by charging and imprisoning them on corruption allegations.

By mid-March, as cases of local transmission began to mount, particularly in large, densely populated cities such as Karachi, Lahore and Peshawar, both opposition parties offered to cooperate to counter the pandemic. The federal government, however, chose to sideline parliament, where the opposition had a strong presence. [fn] Because of the political discord, a special pandemic-related parliamentary committee has been dysfunctional since it was set up on 26 March. Composed of both the federal parliament’s houses, with ruling and opposition party representatives, it was meant to review, monitor and oversee issues related to COVID-19 and its impact on the economy. Hide Footnote  Tensions over the direction of pandemic policy also increased between the centre and Sindh (of which Karachi is the capital), the sole opposition-led province.

On 23 March, Sindh’s Pakistan Peoples Party government was the first to impose a province-wide lockdown. Warning of the health dangers, the provincial government urged the centre to devise a national strategy, including through robust shutdown measures. Addressing the nation on 23 March, Prime Minister Khan, who himself holds the federal health portfolio, initially ruled out a countrywide closure, saying it would adversely affect the poor and working class. [fn] “PM rules out lockdown, disapproves of panic buying”, Dawn , 23 March 2020. Hide Footnote  Calling for national consensus and coordinated efforts before the health crisis turned into “a catastrophe”, Pakistan Peoples Party leader Bhutto Zardari responded, “If we are a poor country, we need to lock down more quickly”. [fn] “If we really care about the poor”, he said, “we need to move faster because the poor are more threatened”. “Bilawal wonders at PM decision of not ordering countrywide lockdown”, Dawn, 23 March 2020. Hide Footnote  The military weighed in, supporting a lockdown and deploying troops countrywide to assist civilian administrations in enforcing it. Hours after the prime minister’s address, the federal government reversed course, agreeing to impose a nationwide shutdown, which it subsequently extended until 31 May.

The initial responses of Pakistan’s four provincial governments varied. Sindh was quick in imposing stringent restrictions on non-essential businesses and public movement. Though hindered by limited resources, it also began to aggressively test people and isolate positive cases. [fn] Editorial, “Sindh leads the way”, Dawn , 28 March 2020; Talat Masood, “Leadership is facing its real test”, The Express Tribune , 2 April 2020. Hide Footnote  The three ruling party-controlled provinces, Balochistan, Khyber Pakhtunkhwa and Punjab, also imposed lockdowns. Yet, apparently guided by the prime minister’s aversion to these measures, they opted for looser restrictions, particularly in Punjab, which soon allowed several types of businesses to reopen.

Tense relations between the government and its rivals also hindered coordination between the capital and opposition-held Sindh and among provinces themselves. The Sindh government held the federal leadership responsible for hampering its response. It argues that Islamabad’s support was insufficient, whether in assisting provincial safety protection schemes or providing pandemic-related medical equipment, which, according to the Sindh government, was available but not equitably distributed. [fn] Amir Wasim, “Barbs fly in NA over fight against Covid-19”, Dawn , 12 May 2020; “PPP calls federal govt “incompetent’, blames it for virus spread”, The News , 2 May 2020. Hide Footnote  Inter-provincial coordination was also poor, echoing friction between Khan and his opponents. [fn] Maleeha Lodhi, “Fault lines in focus”, Dawn, 11 May 2020. Dr Lodhi was Pakistan’s permanent representative to the UN (February 2015-October 2019), and twice appointed Pakistan’s ambassador to the U.S. See also “Sindh’s Murtaza Wahab says federal govt ‘didn’t take lead’ over coronavirus pandemic”, The News, 29 March 2020; “Sindh refutes centre’s claim of providing medical equipment”, Dawn , 17 May 2020. Hide Footnote  The three ruling party-held provinces seemingly took their lead from Islamabad’s aversion to working with Sindh. [fn] Fizza Batool, “Pakistan’s Covid-19 political divide”, South Asian Voices , 12 May 2020. Hide Footnote

Much decision-making related to the pandemic has taken place in the federal capital. The main bodies responsible, set up in mid-March, reflect the government and military leadership’s preference for a centralised approach. On 13 March, the National Security Committee, the apex civil-military body, set up a National Coordination Committee for COVID-19, chaired by the prime minister and including Army Chief Qamar Javed Bajwa, the four provincial chief ministers and senior military officers. The National Command and Operation Centre, which sends the committee recommendations on pandemic policy, is headed by the federal minister for planning and development and includes relevant federal and provincial ministers and also several senior military officers.

The stated objective of setting up these two bodies was to bring the federal and provincial governments and military leadership together. [fn] The National Coordination Committee includes the director general of Inter-Services Intelligence directorate, the military’s premier intelligence agency, and the director general of military operations. The command and cooperation centre, according to a military spokesperson, was formed “to collect, analyse and collate information received from the provinces and forward recommendations” to the coordination committee so that it could “make timely decisions”. “Can’t afford ‘indefinite’ lockdown: DG ISPR”, The Express Tribune , 4 April 2020; “Corona has economic, psycho-social impacts: General Qamar Javed Bajwa”, The News , 23 April 2020. See also Zeeshan Ahmed, “A look inside Pakistan’s Covid-19 response”, The Express Tribune, 2 May 2020. Hide Footnote  In principle, responsibility for the health sector lies with the provinces, not the capital. [fn] The 2010 constitutional amendment, which restored federal parliamentary democracy after a decade of military rule, gives provinces this mandate. Hide Footnote  In practice, however, the top political and military leadership in the centre controls pandemic policy, often overriding provincial concerns, not just in opposition-led Sindh but also in the three ruling party-led federal units.

On 14 April, Prime Minister Khan extended the nationwide lockdown until 30 April but also relaxed restrictions. Several non-essential industries, including construction, reopened. Khan said there was “98 per cent consensus among all provinces and the centre on the reopening of some sectors”. [fn] “PM Imran Khan extends lockdown for two weeks”, The Express Tribune, 14 April 2020. Hide Footnote  Yet the Sindh government, disagreeing, opted to retain stricter measures for another two weeks. While acknowledging that it was constitutionally empowered to so, the federal minister in charge of pandemic response warned the provincial government against resisting Islamabad’s directives. [fn] “PM extends lockdown for two weeks”, The Express Tribune , 15 April 2020; “Centre assails Sindh govt over ‘stricter’ lockdown”, Dawn , 16 April 2020. Hide Footnote  Judicial intervention then strengthened the centre’s control over pandemic policy. In a suo moto (on its own volition) hearing on the virus crisis in mid-April, the Supreme Court chief justice called for a uniform policy, warning Sindh not to close businesses and services that generate revenue for the federation. The Sindh government then gave in to the centre’s wishes. [fn] “Sindh can’t close entities paying taxes to centre: SC”, The Express Tribune , 4 May 2020. Hide Footnote

C. Mixed Messaging and the Power of the Pulpit

The mid-April decision to ease the lockdown and the federal government’s mixed messaging about the pandemic left the public confused about its gravity. Early in the crisis, in a televised address on 17 March, Prime Minister Khan had downplayed health risks. “There is no reason to worry”, he said, since 90 per cent of the infected would have mild flu-type symptoms and 97 per cent would recover fully. [fn] “PM Imran tells nation to prepare for a coronavirus epidemic, rules out lockdown”, Dawn, 17 March 2020. See also Khurram Hussain, “Addressing the confusion”, Dawn , 2 April 2020. Hide Footnote  A mid-April decision to reopen mosques for communal prayers further muddled the state’s message.

When the nationwide lockdown was first imposed, provincial governments barred mosques from holding communal prayers. Mosques remained open but only five mosque administrators could participate in prayers. The police were tasked with enforcing the restrictions, which were largely respected in major cities. When clerics violated the curbs in Karachi, for example, police temporarily detained most offenders; charges were lodged against others for inciting violence against police officers. [fn] “Prayer leader, six others sent to jail on judicial remand in Sindh”, The Express Tribune , 5 April 2020. Hide Footnote  As a result, most mosques in Sindh’s cities complied with the health restrictions. [fn] “Has the federal govt erred by not closing mosques in Ramadan?”, Pakistan Today , 30 April 2020. Hide Footnote

In contrast, Islamabad’s police registered cases but made no arrests when Lal (Red) mosque’s hardline clerics openly violated restrictions. Clerical leader Abdul Aziz released footage of large congregations attending Friday prayers. [fn] Kalbe Ali, “More than 50 clerics warn govt not to further restrictions on prayer congregations”, Dawn , 14 April 2020. Hide Footnote  When the police tried to barricade the mosque’s entrance, female madrasa students blocked the road. [fn] In early June, the federal government reportedly reached agreement with Abdul Aziz, mediated by the leader of a banned sectarian group; the police were to remove blockades in return for Aziz’s commitment to vacate the mosque. “Capital administration, former Lal Masjid cleric reach agreement”, Dawn , 3 June 2020. Hide Footnote  The Khan government might have hesitated in taking action against the Lal Masjid clerics, fearing a repeat of the bloody July 2007 standoff, when a military operation against heavily armed jihadists in the mosque left 100 militants and eleven soldiers dead. [fn] For details of the Lal Masjid operation, see Crisis Group Asia Report N°164, Pakistan: The Militant Jihadi Challenge , 11 March 2009. Hide Footnote  Yet in refraining from taking action, it risked creating a major virus cluster in both the federal capital and its twin city, Rawalpindi.

On 18 April, without consulting provincial governments, President Arif Alvi agreed with major religious leaders to reopen mosques nationwide for communal, including taraweeh (special Ramadan), prayers – but under conditions. [fn] Several senior clerics had warned the federal government against retaining restrictions on mosques. “More than 50 clerics warn govt not to further restrictions on prayer congregations”, Dawn , 14 April 2020. Hide Footnote  The agreement specified safety and health precautions, including social distancing, and tasked mosque administrations with enforcing them. To violate the measures, the president said, “would be like a sin because all ulema and mashaikh (religious scholars and spiritual leaders) have agreed” to them. [fn] “PTI govt, Ulema agree on SOPs for Ramazan amid coronavirus outbreak”, The Express Tribune , 19 April 2020. Hide Footnote  Justifying the decision, Prime Minister Khan said he was heeding popular demand. “Pakistan is an independent nation”, he said. “Ramadan is a month of worship, and people want to go to mosques”. His government “could not forcibly tell them not to do so”. [fn] “‘We are an independent nation’: PM Khan responds to questions over keeping mosques open”, Dawn , 21 April 2020. On 21 April, prominent doctors called on the government and religious leaders to reconsider their agreement, warning that removing curbs on communal prayers would create viral clusters and “unwanted loss of lives”. “Failure to close mosques, control virus in Pakistan may be bad for entire Muslim ummah: doctors”, The News , 21 April 2020. Hide Footnote

Yet many clerics have flouted the agreement’s terms. During Ramadan, when mosque attendance is at its highest, clerics made little effort to enforce the protocols. [fn] A survey of mosques in Punjab and the federal capital during Ramadan found that 85 per cent had violated health and safety protocols. Kamila Hayat, “Duel till death”, The News , 30 April 2020; “Violations of SOPs for mosques aggravates virus situation in KP”, Dawn , 6 May 2020. Hide Footnote  Thousands prayed in packed mosques, ignoring health measures and creating new hot-spots of viral infection. [fn] “Violations of SOPs for mosques aggravates situation in KP”, Dawn, 6 May 2020. Hide Footnote  Many clerics appear to have told worshippers to demonstrate piety by praying shoulder to shoulder, warning that the pandemic is a punishment for erring Muslims’ sins, arguing that the faithful are immune and that life and death are in God’s hands alone. [fn] In an Al Jazeera interview, Lal Masjid cleric Aziz said, “In our [religious leaders’] opinion, this is a punishment from God, and is coming because we have filled the world with sins”. Another religious leader said, “there is no coronavirus. This is just a movement to try and target religion and mosques”. Yet another insisted that the only way to get rid of the virus would be to seek forgiveness from God through prayers in mosques. “Pakistanis gather for Friday prayers defying coronavirus advisory”, Al Jazeera, 17 April 2020; “Mosques remain closed amid strict lockdown”, The Express Tribune , 4 April 2020; “‘God is with us’: Many Muslims flout the coronavirus ban in mosques”, Reuters, 13 April 2020; Kalbe Ali, “More than 50 clerics warn govt not to further restrictions on prayer congregations”, Dawn , 14 April 2020. Hide Footnote  As a result, many who regularly attend mosques either believe they will not contract the virus or that prayer will protect them. [fn] A mid-April survey found that 82 per cent believed that ablution for prayers would prevent infection and 87 per cent that communal prayers could not cause contagion. “Survey shows whopping majority thinks inhaling steam, ablution wards off COVID-19”, The News , 12 April 2020. Hide Footnote  Many also chose not to get tested or treated due to religious and social stigma attached to the disease. [fn] Crisis Group telephone interviews, health professionals, Karachi, Islamabad, May 2020. Hide Footnote

III. The Economy, Health Policy and Social Support

On 9 May, after extending relatively weak pandemic-related restrictions for two weeks, the federal government ended the lockdown. Prime Minister Khan insisted that the decision was taken with the provinces’ consensus, but Sindh’s chief minister said Islamabad imposed its will. [fn] “Sindh CM didn’t announce lifting lockdown from Monday, Bilawal”, The Express Tribune , 9 May 2020; Syed Irfan Raza, “Record Covid-19 cases reported in single day”, Dawn , 9 May 2020. Hide Footnote  The Punjab and Balochistan governments, held by the ruling party, also warned against lifting restrictions. [fn] Raza, “Record Covid-19 cases reported in single day”; “Relaxed curbs will mean 1.1.m cases by July”, The Express Tribune , 9 May 2020. Hide Footnote  The judiciary again weighed in. On 19 May, during the coronavirus suo moto case hearings, the Supreme Court noted that provinces were constitutionally bound to follow Islamabad’s directives. [fn] In a June interview, Sindh’s spokesperson noted, “the court said provinces have to follow the lead and advice of the centre. We never stood a chance [after that]”. Dawn TV, 10 June 2020; “Provinces are bound to follow Centre’s directives: SC”, The Express Tribune , 19 May 2020. Hide Footnote

Though the federal government said it would lift the lockdown in phases, by mid-June the country was almost fully open for business. Schools remained closed but all markets and shopping centres were operating and restrictions on most non-essential businesses had been removed. Borders with Iran and Afghanistan were reopened, domestic and international flights resumed, and several train services started up again, as did local public transport. Punjab reopened shrines that traditionally attract large numbers.

Prime Minister Khan’s justifications for lifting the lockdown were twofold: the burden on the poor and working class, and the adverse impact on the national economy. Announcing the National Coordination Committee’s decision to cancel the closures on 7 May, he said, “We are doing it because people are facing extreme difficulties. Small business owners, daily wage earners and labourers are suffering. We fear that small and medium-sized industries might vanish completely if we don’t lift the lockdown”. [fn] “Govt to end lockdown from 9th in phases”, The Express Tribune, 8 May 2020. Hide Footnote  A week earlier, preparing the ground for the announcement, the federal minister heading the National Command and Operation Centre said the government’s revenues would otherwise fall by 30-35 per cent. [fn] “Lockdown to be further eased, says PM Khan”, Dawn, 1 May 2020. Hide Footnote

The pandemic has seriously compounded Pakistan’s already grave economic challenges. Pakistan’s economy was in dire straits even before COVID-19. Since the Khan government assumed office, large-scale manufacturing has declined, exports have fallen, the budget deficit has widened and unemployment has increased. [fn] Sharoo Malik, “Taking stock: The PTI government’s economic performance in its first year”, South Asian Voices, 8 September 2019; “Pakistan premier’s first year: economic hit and miss”, Dawn, 19 August 2020; Hina Ayra, “Pakistan’s economic options during the coronavirus crisis”, The Express Tribune , 3 April 2020. See also editorial, “GDP growth”, The News , 18 May 2020. Hide Footnote  A former finance minister and financial expert had estimated economic growth in the Khan’s government’s first year at 1.9 per cent, the lowest in a decade. [fn] “Hafiz Pasha says GDP growth is 1.9 per cent”, The News , 8 February 2020. Dr Hafiz Pasha, the former finance minister, is now chair of the Panel of Economists, an independent body advising the government. Hide Footnote  Now, exports to traditional markets – Europe, the U.S., China and the Middle East – are fast declining. [fn] Syed Haris Ahmed, “With lockdowns everywhere, export is a difficult job”, The Express Tribune, 6 April 2020; “Pakistan’s deficit and poverty rate to soar due to coronavirus, govt estimates”, Reuters, 14 May 2020. Hide Footnote  Remittances, a vital source of foreign exchange, are likely to shrink as thousands of workers in the Gulf come home. The government estimates that the gross domestic product will contract by 0.38 per cent for the fiscal year 2019-2020. The World Bank has forecast even sharper drops of 2.6 per cent for 2019-2020 and 0.2 per cent for 2020-2021. [fn] The economy has contracted for the first time since 1951-1952. Pakistan Economic Survey 2019-20 ; “Global Economic Prospects ”, The World Bank, June 2020. Hide Footnote

If the government’s goal in lifting the lockdown was to get the economy moving, little suggests that is happening, even as numbers of new cases mount. Indeed, it has become ever clearer that economic growth depends on curbing the virus. On 22 April, days after the lockdown was first eased, the World Health Organisation’s director general had warned, “Without effective interventions [in Pakistan], there could be an estimated 200K+ cases by mid-July. The impact on the economy could be devastating, doubling the number of people living in poverty”. [fn] “WHO, PMA advise for total lockdown”, The News, 24 April 2020. Hide Footnote  Four months on, signs of economic recovery are still few.

The federal government has provided emergency assistance to families in need, including food subsidies and support, but for many this aid is barely enough. The Ehsaas emergency cash program (the renamed Benazir Income Support Program) provides financial assistance to an estimated twelve million families that fall under the poverty line. [fn] Set up in mid-2008, the federally funded Benazir Income Support Program, the country’s largest social safety net, provides cash assistance exclusively through women to economically vulnerable families. Hide Footnote  Islamabad began the scheme on 9 April and extended it the following month to provide a similar amount to four million unemployed workers. [fn] “PM launches cash disbursal program for workers today”, Dawn , 18 May 2020. Hide Footnote  Yet the lump sum cash transfer of approximately $75 to cover four months of expenses hardly covers food costs.

Such support could well be critical for months. According to Prime Minister Khan, the cash disbursement program can only be a temporary solution, which is why the lockdown was lifted. “There’s no way the government can give out handouts to feed people for that long”. [fn] “Millions would have starved if lockdown wasn’t lifted: PM Khan”, Dawn TV, 21 May 2020. Hide Footnote  Yet with the pandemic continuing to hinder any economic recovery, the need for state assistance appears likely to increase further. A prominent public health expert and demographer noted: “There is no choice but to provide the essentials like food, water and health care for the poorest 20 per cent of the population for the next few months. ... [t]he counterfactual is skyrocketing poverty, malnutrition and deaths of key household members that will be difficult to repair financially and emotionally”. [fn] Zeba Sattar, “Lives not worth saving”, Dawn , 13 June 2020. As Pakistan country director of the Population Council, Dr Sattar evaluates health delivery services. According to the World Food Program , 39.6 per cent of the population faces food insecurity, and Pakistan has the second highest rate of malnutrition in South Asia. Hide Footnote

At the same time, the government’s financial resources are strained, though foreign aid should help. Donors have earmarked additional assistance to help Pakistan cope with the pandemic’s economic impact, including through social protection programs for families in need. The government looks set to receive billions of dollars in pandemic-related aid. [fn] The government will likely receive $1.5 to $2 billion in temporary debt relief from G20 member counties; the International Monetary Fund allocated $1.4 billion through its Rapid Financing Instrument, to mitigate the economic impact of the pandemic; the World Bank restored Pakistan’s budgetary support and granted a $500 million loan for pandemic-related health care and social safety nets; the Asian Development Bank approved a $500 million loan for the government’s health and economic response, including social protection for the poor. Bilateral donors, such as Germany, have also extended assistance, with Berlin providing 0.5 million euros to help Pakistan overcome the pandemic’s socio-economic impact at the local level. “Germany backs Pakistan’s efforts to mitigate socio-economic impact of Covid-19”, Dawn, 27 July 2020; “Pakistan to receive $500m loan from ADB to help fight coronavirus, ‘protect poor’”, The News, 10 June 2020; “WB okays $500m loan to help government fight Covid-19”, Dawn , 23 May 2020; “Pakistan wins $1.4b IMF emergency loan”, The Express Tribune , 17 April 2020; Arsalaan Asif Soomro, “Can Pakistan’s economy endure the ramifications of COVID-19?”, The Express Tribune, 15 April 2020. Hide Footnote

The dire economic situation risks playing into militants’ hands, particularly if social support measures fall short. As unemployment rises further and more citizens fall under the poverty line, such groups could exploit the ensuing social discord. If the state fails to deliver, they could have new opportunities to win recruits by tapping economic desperation and social grievances or extending assistance through existing or renamed charities, as they have in the past. [fn] Militant groups have in the past enhanced their local appeal by providing food and other assistance through their charity wings, including after the 2005 earthquake in Pakistan and Pakistan-administered Kashmir. See Crisis Group Asia Briefing N°46, Pakistan: Political Impact of the Earthquake , 15 March 2006. Hide Footnote

IV. Health Systems in a Pandemic

Pakistan’s under-funded health care system is ill equipped to deal with an unprecedented public health emergency. [fn] There are around six hospital beds, 9.8 doctors and five nurses per 100,000 population in Pakistan. Health expenditure is among the lowest in the world, estimated by the World Health Organisation at 2.9 per cent of GDP. “Time to step up”, The News , 23 March 2020. Hide Footnote  Medical professionals have repeatedly called for a stringent nationwide lockdown until transmission rates decline. But the government, concerned about the economic costs, rejects their advice. In some cases, ruling-party leaders have even dismissed concerns as partisan. When positive COVID-19 cases increased by 40 per cent nationwide soon after the lockdown was eased in mid-April, Karachi-based health experts and doctors called for stricter restrictions, warning that major hospitals in the city were overstretched. [fn] “Covid-19 cases up by 40% in five days, doctors”, The Express Tribune , 23 April 2020; “WHO, PMA advise for total lockdown”, op. cit. Hide Footnote  A ruling-party leader accused them of criticising the federal government on behalf of the Pakistan Peoples Party opposition. [fn] “Gill accuses Sindh govt of politicising corona situation thru doctors”, The News , 24 April 2020. Shahbaz Gill has since, in mid-May, been appointed the prime minister’s special assistant on political communication. Also Iftikhar A. Khan, “PPP asks centre to stop playing ‘pandemic politics’”, Dawn , 25 April 2020. Hide Footnote  Professional bodies of doctors countrywide have issued similar calls for a nationwide closure to contain the disease’s spread both before 9 May and afterward. [fn] “Doctors demand strict lockdown, urge religious scholars to review decision to open mosques”, Dawn , 22 April 2020; Amer Malik, “Health care in a fix”, The News, 31 May 2020. Hide Footnote

While the decision on when to lift the lockdown would always involve difficult trade-offs, the government appears to have moved too early. Retaining a nationwide lockdown indefinitely would not have been feasible for economic reasons and due to public fatigue. As Prime Minister Khan says, the lockdown took a heavy toll on impoverished Pakistanis, who survive at subsistence level and need handouts if they cannot leave their homes to work. A protracted nationwide lockdown would have risked fuelling public anger as much as the health emergency. Yet reopening the economy and the country as early as was done, without adequate testing, tracing, isolating and treating the infected, led to a sharp spike in cases. By 9 May, when the lockdown was lifted, the total number of cases was around 29,000 and the death toll was 637. About six weeks later, the total number of cases were more than 175,000; the death toll stood at over 3,000. [fn] “Sindh reports highest single day increase nationwide; nationwide tally soars to 28,818”, The Express Tribune , 9 May 2020; “Pakistan crosses 3,000 deaths due to COVID-19”, Newsweek Pakistan, 18 June 2020; “Pakistan reports 4,471 cases of Covid-19 in a day”, The Nation , 22 June 2020. Hide Footnote

In early June, the World Health Organisation’s Pakistan country head recommended imposing targeted and intermittent two-week-on, two-week-off lockdowns. His letter to the Punjab health minister noted that the country met none of the prerequisites for fully lifting restrictions, including containing disease transmission, detecting, testing, isolating and treating all cases, minimising hot-spots and ensuring preventive measures in workplaces and other public spaces. [fn] “WHO recommends ‘intermittent, targeted’ lockdowns in Pakistan”, The Express Tribune, 9 June 2020. Hide Footnote  Health experts were quick to support his recommendation. But the prime minister’s health adviser said the WHO had assessed Pakistan’s situation through a “health lens” and that the government has “to make tough policy choices to strike a balance between lives and livelihoods”. [fn] “WHO says Pakistan meets no pre-requisite for easing restrictions, recommends ‘intermittent lockdown’”, Dawn, 9 June 2020; “Corona killing four an hour in Pakistan”, The News, 11 June 2020. Hide Footnote

Instead, the federal government has opted for what it calls “smart lockdowns”, a policy it adopted when easing pandemic-related restrictions in mid-April. Its limited lockdowns differ from those recommended by the WHO in that they apply only to specific localities within cities or rural districts where positive cases are high. The government eased or removed them altogether in low-risk areas. [fn] Inter-Services Intelligence, the military’s main intelligence arm, has been tasked with tracing infected persons and their contacts through geo-fencing and phone monitoring systems that it uses for counter-terrorism purposes. Ramsha Jahangir, “Over 5,000 people at risk of contracting Covid-19 identified by track system”, Dawn , 2 May 2020. Hide Footnote  In mid-June, provincial governments imposed two-week lockdowns in areas of cities such as Karachi, Lahore and Peshawar. [fn] On 15 June, the National Command and Operation Centre identified virus clusters in twenty cities across the country. According to a press release from his office, Prime Minister Khan had directed the provincial governments to impose smart lockdowns “in sensitive areas keeping in view ground realities to maintain a balance between economic activities and preventive measures”. Syed Irfan Raza, “PM satisfied with virus testing kits, PPE availability”, Dawn, 16 June 2020. Hide Footnote  The government argues that such limited lockdowns can contain virus spread without economic hardship.

By 2 August, Pakistan had around 280,200 registered cases and close to 6,000 deaths, ranking thirteenth among COVID-19 affected countries globally (in terms of total cases). [fn] See Pakistan’s official COVID-19 website or the Worldometers website for numbers. The death toll is likely under-counted since many families, fearing the religious and social stigma of the disease, do not report infections or seek treatment. The Khyber Pakhtunkhwa government, for instance, is investigating declining mortality figures, to check if patients are dying unrecorded at home. “Govt probing causes of decline in Covid-19 deaths”, Dawn , 23 July 2020. Hide Footnote  According to official statistics, the daily number of confirmed cases has declined considerably since mid-July. The government attributes the reduction to its smart lockdowns. [fn] The prime minister’s health adviser said the government had managed to contain the pandemic through the smart lockdown strategy. “Pakistan’s preparation and response to the coronavirus outbreak has been one of the best in the world”. “Over 204,000 recover from disease as curve flattens”, The Express Tribune , 20 July 2020. Hide Footnote  Yet reduced testing may also partly explain it: official data shows daily nationwide testing rates dropping from on average around 28,500 in June to fewer than 22,00o in July. [fn] In June, the WHO had recommended that Pakistan increased daily testing capacity to 50,000. Daily test numbers, however, fell from the end of June. By 2 August, according to the Worldometers website, Pakistan had conducted 2,010,170 tests for around 220 million citizens: 9,086 per one million population. See also “Pakistan: Situation Report (as of 10 June 2020)”, UN Office for the Coordination of Humanitarian Affairs. Hide Footnote

The smart lockdown’s “track, trace and quarantine” strategy, which involves tracing and isolating virus carriers and their contacts and placing viral hot-spots under quarantine, is hampered by poor data and low testing rates. [fn] Crisis Group interviews, doctors, Karachi, July 2020. Hide Footnote  In June, the minister overseeing the pandemic response had said that authorities would increase daily testing capacity to 100,000 by July. [fn] “Just in a month: Pakistan faced 242pc surge in deaths”, The News , 15 June 2020. Hide Footnote  According to the National Command Operation Centre, testing capacity had increased to over 70,000 by early July. [fn] Calling for increased testing, a doctors’ forum said that the government’s figures of confirmed cases are “not representative of the actual ground situation”, “Doctors’ forum stresses need to enhance Covid-19 testing in Pakistan”, Dawn , 12 July 2020; “Covid-19: Data shows Pakistan utilising only a third of its testing capacity”, The News , 8 July 2020. Hide Footnote  Yet less than one third of that capacity is now being used. [fn] Observers offer various reasons for the decline in testing: international travellers are no longer tested on arrival; groups that were previously targeted, such as Tableeghi Jamaat, journalists and government officials, are no longer tested systematically; tests’ costs mean they are used only for patients with serious symptoms; and, with numbers declining, fewer tests are necessary. Hide Footnote  With the virus appearing in many localities in densely populated cities, limited lockdowns of a few blocks of a city or a part of a rural district appear unlikely to contain it. A Pakistani expert on viral diseases said, “Incomplete lockdowns mean the virus has a chance of finding new hosts”. [fn] Tufail Ahmed, “Containing pandemic: Don’t bother with partial lockdowns, says expert”, The Express Tribune , 16 June 2020. Hide Footnote

The forthcoming religious holidays threaten another uptick. The lifting of nationwide restrictions during Ramadan in June and for Eidul Fitr contributed to the first surge of infections as massive crowds shopped in markets and large congregations prayed in mosques. The government and doctors fear the virus could once again peak should the public disregard safety measures in August during Eidul Azha festivities and in Muharram, when large mourning processions are held. [fn] Prime Minister Khan said, “if we are careless on Eidul Azha, the virus could spread again and there could be a fresh spike of infections”. “PM warns of virus spike of SOPs violated on Eid”, Dawn , 10 July 2020. Hide Footnote  Spiralling numbers of cases could once again overwhelm hospitals and clinics. With case numbers increasing substantially in smaller cities and rural regions, their weaker health facilities could soon be overrun.

V. Conclusion

Chairing a meeting of the National Coordination Council on 1 June, Prime Minister Khan said, “a lockdown isn’t a solution or treatment. … Nothing can be done about it. The virus will spread, and our death toll will also rise” until a vaccine is found. He added, “If we have to live successfully with the virus, it is the responsibility of the people. If they take precautionary measures, we can tackle the virus and live with it”. [fn] Khan also decided to further ease the few remaining restrictions, including on domestic tourism. “Pakistan to ease lockdown, open more businesses amid surging COVID-19 infections”, The News , 1 June 2020; “PM Khan bats for unlocking economy, eases coronavirus lockdown”, The Express Tribune , 2 June 2020. Hide Footnote  Placing the onus of preventing contagion on citizens also appears at the heart of a new strategy, “Living with the Pandemic”, discussed by the Command and Operation Centre a day earlier. [fn] “88 deaths, 3,039 new cases in a single day: Provinces differ over smart lockdown”, The News , 1 June 2020; “NCOC mulls over ‘living with the pandemic strategy’ to cope with coronavirus”, The News, 30 May 2020. Hide Footnote

Mixed and confused signalling by Prime Minister Khan and his top advisers early in the crisis mean that people often now ignore their calls to observe social distancing and other health guidelines. Many still believe that the pandemic has ended, and largely brush off calls for responsible public behaviour. Public health specialists also warn that “leaving people to determine the rules of restoring normality could prove fatal if growth in cases and deaths continues at average rates or may even increase further”. [fn] “Easing Lockdown in Pakistan: Inevitable but Potentially Catastrophic”, Institute of Public Health, Jinnah Sindh Medical University, May 2020. Hide Footnote

A rethink is urgently needed. Federal policy should be based on the best available medical advice, even while factoring in social and economic costs. The government should continue to guide the provinces on pandemic policy, including by helping them shore up health facilities and making preventive measures, such as enforcing the use of face masks outdoors. Yet Islamabad should also allow provincial authorities to devise tailored strategies, guided by medical experts, as they confront new challenges. Not only is health a provincial responsibility, but provincial leaders are better placed to adapt to local needs. Both federal and provincial authorities should also prioritise funding for the health sector.

Islamabad could consider revising its smart lockdown strategy. If deemed necessary, and based on medical advice, provinces should be allowed to shut down entire cities and rural districts with high infection rates for limited periods to interrupt virus transmission. In areas where the virus transmission rate is lower, they should enhance testing, contact tracing and treating the infected. Lockdowns along these lines should be better able to contain virus spread without too onerous a burden on the economy.

Efforts to build the capacity of health care facilities to prevent a repeat of the crisis in June, when cases surged, should continue. In June, intensive care units and beds in major cities like Karachi, Lahore and Peshawar reached or neared capacity. [fn] By early June, critical care wards for COVID-19 patients in some of Karachi’s major government and private hospitals were full to capacity. Hospitals in Lahore were also under strain. Crisis Group telephone interviews, doctors, nurses, Karachi, Lahore, June 2020. Hide Footnote  The provinces have since bolstered health facilities for COVID-related cases, including with federal assistance. [fn] “NDMA reaches target of 2,000 oxygenated beds in hospitals across Pakistan”, The Express Tribune , 22 July; “Sindh has 253 million beds for Covid-19 patients”, The Express Tribune, 14 July 2020. Hide Footnote  Pressures on hospitals have also eased since patients with moderate symptoms are now isolated at home. Yet another sharp surge of infections could once again overwhelm that capacity.

Lastly, instead of bypassing parliament, the federal government should work with the opposition. The parliament should play a more active role, particularly with regard to fiscal and other assistance for the most vulnerable sections of the population. The federal government’s continued targeting of top opposition leaders, including through the National Accountability Bureau, is particularly unhelpful. The Khan government itself would benefit from mending fences with its rivals. The military leadership might be an equal, if not dominant, partner in the pandemic response. Yet citizens will hold the elected leadership accountable if the pandemic response falters. Sharing responsibility with opposition leaders for what are difficult and contentious decisions would not only benefit Pakistan’s body politic but also make sense for the premier himself. The alternative is that COVID-19 leaves a weakened federal government even more reliant on the military to retain power.

Karachi/Islamabad/Brussels, 7 August 2020

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Read these 12 moving essays about life during coronavirus

Artists, novelists, critics, and essayists are writing the first draft of history.

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The world is grappling with an invisible, deadly enemy, trying to understand how to live with the threat posed by a virus . For some writers, the only way forward is to put pen to paper, trying to conceptualize and document what it feels like to continue living as countries are under lockdown and regular life seems to have ground to a halt.

So as the coronavirus pandemic has stretched around the world, it’s sparked a crop of diary entries and essays that describe how life has changed. Novelists, critics, artists, and journalists have put words to the feelings many are experiencing. The result is a first draft of how we’ll someday remember this time, filled with uncertainty and pain and fear as well as small moments of hope and humanity.

At the New York Review of Books, Ali Bhutto writes that in Karachi, Pakistan, the government-imposed curfew due to the virus is “eerily reminiscent of past military clampdowns”:

Beneath the quiet calm lies a sense that society has been unhinged and that the usual rules no longer apply. Small groups of pedestrians look on from the shadows, like an audience watching a spectacle slowly unfolding. People pause on street corners and in the shade of trees, under the watchful gaze of the paramilitary forces and the police.

His essay concludes with the sobering note that “in the minds of many, Covid-19 is just another life-threatening hazard in a city that stumbles from one crisis to another.”

Writing from Chattanooga, novelist Jamie Quatro documents the mixed ways her neighbors have been responding to the threat, and the frustration of conflicting direction, or no direction at all, from local, state, and federal leaders:

Whiplash, trying to keep up with who’s ordering what. We’re already experiencing enough chaos without this back-and-forth. Why didn’t the federal government issue a nationwide shelter-in-place at the get-go, the way other countries did? What happens when one state’s shelter-in-place ends, while others continue? Do states still under quarantine close their borders? We are still one nation, not fifty individual countries. Right?

Award-winning photojournalist Alessio Mamo, quarantined with his partner Marta in Sicily after she tested positive for the virus, accompanies his photographs in the Guardian of their confinement with a reflection on being confined :

The doctors asked me to take a second test, but again I tested negative. Perhaps I’m immune? The days dragged on in my apartment, in black and white, like my photos. Sometimes we tried to smile, imagining that I was asymptomatic, because I was the virus. Our smiles seemed to bring good news. My mother left hospital, but I won’t be able to see her for weeks. Marta started breathing well again, and so did I. I would have liked to photograph my country in the midst of this emergency, the battles that the doctors wage on the frontline, the hospitals pushed to their limits, Italy on its knees fighting an invisible enemy. That enemy, a day in March, knocked on my door instead.

In the New York Times Magazine, deputy editor Jessica Lustig writes with devastating clarity about her family’s life in Brooklyn while her husband battled the virus, weeks before most people began taking the threat seriously:

At the door of the clinic, we stand looking out at two older women chatting outside the doorway, oblivious. Do I wave them away? Call out that they should get far away, go home, wash their hands, stay inside? Instead we just stand there, awkwardly, until they move on. Only then do we step outside to begin the long three-block walk home. I point out the early magnolia, the forsythia. T says he is cold. The untrimmed hairs on his neck, under his beard, are white. The few people walking past us on the sidewalk don’t know that we are visitors from the future. A vision, a premonition, a walking visitation. This will be them: Either T, in the mask, or — if they’re lucky — me, tending to him.

Essayist Leslie Jamison writes in the New York Review of Books about being shut away alone in her New York City apartment with her 2-year-old daughter since she became sick:

The virus. Its sinewy, intimate name. What does it feel like in my body today? Shivering under blankets. A hot itch behind the eyes. Three sweatshirts in the middle of the day. My daughter trying to pull another blanket over my body with her tiny arms. An ache in the muscles that somehow makes it hard to lie still. This loss of taste has become a kind of sensory quarantine. It’s as if the quarantine keeps inching closer and closer to my insides. First I lost the touch of other bodies; then I lost the air; now I’ve lost the taste of bananas. Nothing about any of these losses is particularly unique. I’ve made a schedule so I won’t go insane with the toddler. Five days ago, I wrote Walk/Adventure! on it, next to a cut-out illustration of a tiger—as if we’d see tigers on our walks. It was good to keep possibility alive.

At Literary Hub, novelist Heidi Pitlor writes about the elastic nature of time during her family’s quarantine in Massachusetts:

During a shutdown, the things that mark our days—commuting to work, sending our kids to school, having a drink with friends—vanish and time takes on a flat, seamless quality. Without some self-imposed structure, it’s easy to feel a little untethered. A friend recently posted on Facebook: “For those who have lost track, today is Blursday the fortyteenth of Maprilay.” ... Giving shape to time is especially important now, when the future is so shapeless. We do not know whether the virus will continue to rage for weeks or months or, lord help us, on and off for years. We do not know when we will feel safe again. And so many of us, minus those who are gifted at compartmentalization or denial, remain largely captive to fear. We may stay this way if we do not create at least the illusion of movement in our lives, our long days spent with ourselves or partners or families.

Novelist Lauren Groff writes at the New York Review of Books about trying to escape the prison of her fears while sequestered at home in Gainesville, Florida:

Some people have imaginations sparked only by what they can see; I blame this blinkered empiricism for the parks overwhelmed with people, the bars, until a few nights ago, thickly thronged. My imagination is the opposite. I fear everything invisible to me. From the enclosure of my house, I am afraid of the suffering that isn’t present before me, the people running out of money and food or drowning in the fluid in their lungs, the deaths of health-care workers now growing ill while performing their duties. I fear the federal government, which the right wing has so—intentionally—weakened that not only is it insufficient to help its people, it is actively standing in help’s way. I fear we won’t sufficiently punish the right. I fear leaving the house and spreading the disease. I fear what this time of fear is doing to my children, their imaginations, and their souls.

At ArtForum , Berlin-based critic and writer Kristian Vistrup Madsen reflects on martinis, melancholia, and Finnish artist Jaakko Pallasvuo’s 2018 graphic novel Retreat , in which three young people exile themselves in the woods:

In melancholia, the shape of what is ending, and its temporality, is sprawling and incomprehensible. The ambivalence makes it hard to bear. The world of Retreat is rendered in lush pink and purple watercolors, which dissolve into wild and messy abstractions. In apocalypse, the divisions established in genesis bleed back out. My own Corona-retreat is similarly soft, color-field like, each day a blurred succession of quarantinis, YouTube–yoga, and televized press conferences. As restrictions mount, so does abstraction. For now, I’m still rooting for love to save the world.

At the Paris Review , Matt Levin writes about reading Virginia Woolf’s novel The Waves during quarantine:

A retreat, a quarantine, a sickness—they simultaneously distort and clarify, curtail and expand. It is an ideal state in which to read literature with a reputation for difficulty and inaccessibility, those hermetic books shorn of the handholds of conventional plot or characterization or description. A novel like Virginia Woolf’s The Waves is perfect for the state of interiority induced by quarantine—a story of three men and three women, meeting after the death of a mutual friend, told entirely in the overlapping internal monologues of the six, interspersed only with sections of pure, achingly beautiful descriptions of the natural world, a day’s procession and recession of light and waves. The novel is, in my mind’s eye, a perfectly spherical object. It is translucent and shimmering and infinitely fragile, prone to shatter at the slightest disturbance. It is not a book that can be read in snatches on the subway—it demands total absorption. Though it revels in a stark emotional nakedness, the book remains aloof, remote in its own deep self-absorption.

In an essay for the Financial Times, novelist Arundhati Roy writes with anger about Indian Prime Minister Narendra Modi’s anemic response to the threat, but also offers a glimmer of hope for the future:

Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it.

From Boston, Nora Caplan-Bricker writes in The Point about the strange contraction of space under quarantine, in which a friend in Beirut is as close as the one around the corner in the same city:

It’s a nice illusion—nice to feel like we’re in it together, even if my real world has shrunk to one person, my husband, who sits with his laptop in the other room. It’s nice in the same way as reading those essays that reframe social distancing as solidarity. “We must begin to see the negative space as clearly as the positive, to know what we don’t do is also brilliant and full of love,” the poet Anne Boyer wrote on March 10th, the day that Massachusetts declared a state of emergency. If you squint, you could almost make sense of this quarantine as an effort to flatten, along with the curve, the distinctions we make between our bonds with others. Right now, I care for my neighbor in the same way I demonstrate love for my mother: in all instances, I stay away. And in moments this month, I have loved strangers with an intensity that is new to me. On March 14th, the Saturday night after the end of life as we knew it, I went out with my dog and found the street silent: no lines for restaurants, no children on bicycles, no couples strolling with little cups of ice cream. It had taken the combined will of thousands of people to deliver such a sudden and complete emptiness. I felt so grateful, and so bereft.

And on his own website, musician and artist David Byrne writes about rediscovering the value of working for collective good , saying that “what is happening now is an opportunity to learn how to change our behavior”:

In emergencies, citizens can suddenly cooperate and collaborate. Change can happen. We’re going to need to work together as the effects of climate change ramp up. In order for capitalism to survive in any form, we will have to be a little more socialist. Here is an opportunity for us to see things differently — to see that we really are all connected — and adjust our behavior accordingly. Are we willing to do this? Is this moment an opportunity to see how truly interdependent we all are? To live in a world that is different and better than the one we live in now? We might be too far down the road to test every asymptomatic person, but a change in our mindsets, in how we view our neighbors, could lay the groundwork for the collective action we’ll need to deal with other global crises. The time to see how connected we all are is now.

The portrait these writers paint of a world under quarantine is multifaceted. Our worlds have contracted to the confines of our homes, and yet in some ways we’re more connected than ever to one another. We feel fear and boredom, anger and gratitude, frustration and strange peace. Uncertainty drives us to find metaphors and images that will let us wrap our minds around what is happening.

Yet there’s no single “what” that is happening. Everyone is contending with the pandemic and its effects from different places and in different ways. Reading others’ experiences — even the most frightening ones — can help alleviate the loneliness and dread, a little, and remind us that what we’re going through is both unique and shared by all.

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Socio-economic and environmental impacts of COVID-19 pandemic in Pakistan—an integrated analysis

Rizwan rasheed.

1 Sustainable Development Study Centre, Government College University Lahore, Katchary Road, Lower Mall, Lahore, 54000 Pakistan

Asfra Rizwan

Hajra javed, faiza sharif, asghar zaidi.

2 Office of the Vice Chancellor, Government College University Lahore, Lahore, Pakistan

Associated Data

Not applicable.

The COVID-19 pandemic has affected about 210 countries with more than 67 million confirmed cases and over 1.5 million deaths across the globe including Pakistan. Considering the population density, health care capacity, existing poverty and environmental factors with more than 420,000 infected people and about 8300 plus mortalities, community transmission of the coronavirus happened rapidly in Pakistan. This paper analyses the short- and long-term effects of COVID-19 peak on the socio-economic and environmental aspects of Pakistan. According to the estimates, an economic loss of about 10%, i.e. 1.1 trillion PKR, will be observed in the FY 2021. Certain pandemic impediment measures like lockdowns, social distancing and travel restrictions taken by the Government have been thoroughly analysed to determine how they impacted the livelihoods of nearly 7.15 million workers. Consequently, a rise of 33.7% of poverty level is projected. While many negative impacts on primary, secondary and tertiary sectors of the economy such as agriculture, education and health care are observed, a drastic improvement in air quality index of urban centres of the country has been recorded amid lockdowns. With current economic crisis, fragile health care system and critical health literacy, a well-managed and coordinated action plan is required from all segments of the society led by the public authorities. Thorough assessment of COVID-19 scenario, management and control measures presented in this study can be assistive for the provision of policy guidelines to governments and think tanks of countries with similar socio-economic and cultural structure.

Introduction

Viral diseases have continued to emerge and present a significant threat to public health, according to the “World Health Organization” (WHO). Wuhan, the largest metropolitan area in Hubei province of China, reported for the first time clusters of cases which had unexplained low respiratory infections to the WHO country office on December 31, 2019. The beginning of these symptomatic individuals can be traced back to the start of December 2019, according the survey of published literature (Cascella et al. 2020 ; Sahin et al. 2020 ). Since the causative agent was not identified, therefore, these first cases were termed as “pneumonia of unknown aetiology.” After thorough investigation of the intensive outbreak by the “Chinese Centre for Disease Control and Prevention” (CDC), the aetiology of the illness was recognized as pneumonia caused by a novel virus. The virus belongs to the coronavirus (CoV) family and was named as the novel coronavirus pneumonia and was termed as 2019-nCov by the Chinese researchers (Zhu et al. 2020 ). Later on, it was named as “severe acute respiratory syndrome coronavirus-2” by the “International Committee on Taxonomy of Virus” (Zu et al. 2020 ). On February 11, 2020, the WHO named the pneumonia as coronavirus disease-19 also known as COVID-19 (Li et al. 2020 ; Waris et al. 2020 ).

On January 30, 2020, the WHO declared the outbreak of coronavirus disease as the sixth public health of emergency services. This outbreak is not the first as previous outbreaks of coronavirus have occurred. These include the severe acute respiratory syndrome coronavirus (SARS-CoV) in 2002–2003, and most recently, in 2012 the Middle East respiratory syndrome coronavirus (MERS-CoV) was identified for the first time in Saudi Arabia. COVID-19 is, therefore, being considered as the third coronavirus outbreak which has affected over 200 countries all over the globe including Pakistan (Waris et al. 2020 ; Zhou et al. 2020 ).

On March 11, 2020, the number of cases reported outside China were 13 times more than that reported in China, i.e. 118,000 cases in 114 countries and more than 4000 deaths; therefore, COVID-19 was declared as a pandemic by the WHO (Cascella et al. 2020 ; Di Gennaro et al. 2020 ). As per the current statistics reported by the WHO, there are 67,618,431 confirmed cases of COVID-19 globally, and 1,544,985 mortalities have been reported (WHO 2020b ). As of now, the USA, followed by India, Brazil, Russia, France and Italy have reported the highest number of positive cases (Table ​ (Table1) 1 ) (GoP 2020 ). If compared with the developed countries which are having state-of-the-art health care and testing facilities, the performance of Pakistan in flattening the COVID-19 curve during the first wave has been quite astonishing. In the mid-August, the global COVID-19 cases surpassed 23 million with more than 810,000 fatalities, but in Pakistan, around 292,000 infected cases were recorded with 6200 mortalities. This has been attributed to the smart lockdown scheme launched by the government which involved identification of COVID hotspots across Pakistan and isolating those specific areas. The second factor is the high youth population in Pakistan. The countries which have been at the worst hit had population with an average age of 35–45. Moreover, various surveys have highlighted that a few cities and not the whole country are showing signs of widespread herd immunity. This phenomenon is helping the population to cope with the novel coronavirus (Kermani 2020 ) .

Statistics of top 15 COVID-19-affected countries (as of December 6, 2020)

The bordering countries of Pakistan have been severely hit by the coronavirus such as China which is the epicentre of COVID-19 having 4634 deaths. While Iran situated in the North also has very high number of fatalities which were recorded as 50,594. The very first case of COVID-19 in Pakistan was reported by the “Ministry of Health, Government of Pakistan” on February 26, 2020, in Karachi (Ali et al. 2020 ; Malik 2020 ). While on the same day “Pakistan Federal Ministry of Health” confirmed another case in the federal capital, Islamabad. Within a span of 15 days, the number of suspected cases was reported to be 471 in which the confirmed cases of COVID-19 were 20 (4.25%). The province of Sindh had the highest number of cases, i.e. 14 followed by 5 in Gilgit-Baltistan and 1 in Baluchistan. All the positive cases were reported to have recently travelled to Iran, Syria and London (Waris et al. 2020 ; Saqlain et al. 2020 ).

The geographical location of our country and the constant increase in the number of COVID-19-infected cases suggested that there was a dire need of strategic preparedness and prompt actions were required to control the situation before it becomes worse. The “Ministry of National Health Services, Regulation and Coordination Pakistan” on February 12, 2020, presented a “National Action Plan” in response to COVID-19 so that the spread of the virus can be controlled. Furthermore, its objective is to strengthen the emergency preparedness of the community and the country as a whole so that a timely and effective response could be made in respect to the evolving situation regarding COVID-19. The government of Pakistan to date has taken various steps (NIH 2020 ; Waris et al. 2020 ).

Current situation

A total of 420,294 cases have been reported by the “Ministry of Health, Government of Pakistan” in the country out of which 8588 are active cases and 6523 deaths as of October 6, 2020. Since now Pakistan is facing the 2nd COVID-19 peak, the active cases have risen to 55,354 and 8398 deaths have occurred. The total number of recovered cases recorded was 300,616 whereas 3,702,607 tests have been conducted all over the country as of October 6, 2020. Currently the recovered cases reported are 356,542 with 5,794,242 total number of tests. (Fig.  1 ). The highest number of positive cases has been reported by the province of Sindh, followed by Punjab, Khyber Pakhtunkhwa (KPK), Federal (ICT), Baluchistan, Azad Jammu and Kashmir and Gilgit-Baltistan. The highest number of mortalities has been reported by the province of Punjab followed by Sindh and KPK. Sindh has the highest number of recovered patients with Punjab second and KPK third. The details have been summarized in Table ​ Table2. 2 . The mortality rate in reference to the positive cases in Pakistan is 2.0% with 95.2% recovery rate (as of October 6, 2020). Currently during the second peak, the recovery rate has dropped to 84.8%. (GoP 2020 ).

COVID 19 outbreak figures (as of October 6, 2020) of Pakistan

Current province wise COVID-19 outbreak figures (as of December 6, 2020)

In an attempt to understand the turmoil effects of the novel coronavirus pandemic on the society, environment and the economy, this study summarizes the socio-economic and environmental impacts of COVID-19 in Pakistan. Until date no such study has been conducted which highlights the integrated socio-economic and environmental impacts resulted due to the peak of the global viral outbreak in Pakistan. This study aims to forecast the possible short- and long-term effects of the pandemic on the emerging economy, society and the environment by considering the current discussions. The aim is to analyse the peak period of the COVID-19 pandemic and the subsequent lockdown strategy adopted to curb the spread so to fill the current knowledge gap by providing a thorough insight of the current socio-economic crises being faced by the resource-limited settings of Pakistan. This assessment can prove to be useful for the government, policymakers and practitioners of Pakistan as well as of countries having similar socio-economic and cultural structure like Pakistan.

This paper is structured into 8 main sections with first section being the “ Introduction ”. After the Introduction, the “ COVID-19 vs previous epidemics—comparative clinical and economic analysis ” section compares COVID-19 with previous epidemics drawing a comparative clinical and economic analysis. The “Health system and response in Pakistan” section highlights the health care system of Pakistan and its subsequent response to the current pandemic. The “ State of environment and pollution ” section presents the effect of the pandemic on the environment and pollution. The “ Agriculture sector and food security ” section is based on the impact faced by the agricultural sector and consequent food security issue, whereas “Poverty and labour market” is addressed in the “ Poverty and labour market ” section. “Socio-economic impacts” due to the COVID-19 pandemic have been analysed in the “ Socio-economic impacts ” section. The “ COVID-19: measures and lessons ” section presents the containment measures and lessons learnt for Pakistan. The “ Conclusion and the way forward ” section concludes the study while highlighting what should be our way forward with this pandemic.

COVID-19 vs previous epidemics—comparative clinical and economic analysis

Drawing comparative inferences between previously encountered wide-reaching epidemics and the newly emerging outbreaks holds critical significance for the health sector and economic policymakers alike. These relative evaluations provide baseline guidance for assessing the efficiency and community response to the existing policy frameworks in controlling such biological risks. This also leads towards making certain needful improvisations in the important state sectors as a proactive response for effectually controlling similar outbreaks in future, based on the lessons from previous experiences (Lai et al. 2020 ). The novel COVID-19 has been regarded as a global pandemic by the World Health Organization (WHO) on March 11, 2020, considering its wide-scale impacts and mortalities. The previous viral outbreaks including the “severe acute respiratory syndrome” (SARS) in 2003, “Middle East respiratory syndrome” which occurred in 2012 and Spanish flu (H1N1) which affected the human community from 1918 to 1919 all involved closely related strains of influenza virus that were also responsible for pneumonia (Baldo et al. 2016 ; Barro et al. 2020 ; Liu et al. 2020 ).

While all these epidemic events adversely impacted the humankind in terms of thousands of lives lost and economic setbacks, but only Spanish flu outbreak in 1918–1919 can be regarded as a true pandemic which can be related to COVID-19 in disease intensity and scale of infection. The viral flu of the twentieth century which resulted in loss of approximately 30% of the global population had held the research interests of epidemiologists around the world for decades in controlling its contagion effects and lasting ramifications (Lai et al. 2020 ; Lilley et al. 2020 ; Verikios 2020 ). With its first case reported in a Spanish newspaper, this flu became a world-reaching pandemic due to its exponential transmission in the soldiers returning to their homelands at the end of the World War I. Affecting more than 200 countries of the world, this pandemic of the twentieth century can be regarded as the closest parallel of the modern coronavirus in view of its severity and global outreach. Despite of the presence of extensive research data on previous viral epidemics, the scale of impact of COVID-19 is still unprecedented (Di Gennaro et al. 2020 ; Liu et al. 2020 ).

Epidemiological analysis

Studying the human response and epidemiological patterns of previous epidemic events of the twentieth and twenty-first centuries can help in anticipating the trajectory of the recent pandemic. Moreover, it can provide factual inferences for controlling the exponential transmission rate while devising new combinations of different medications with high possible efficiency. First case of COVID-19 was diagnosed in Wuhan, China, in the end of 2019 and then the number of infected cases and mortalities multiplied within days. The disease has now been controlled to a major extent in China; however, it has impacted 85,482 people and took 4634 lives in China alone as of May 14, 2020, with a worldwide mortality rate nearing that of the Spanish flu. Moreover, the virulence of this novel viral strain has been observed to be significantly higher than any previous flu epidemics encountered by the human history (Liu et al. 2018 ; Sun et al. 2020 ; Rothan and Byrareddy 2020 ). In addition to this, two other epidemiological variables considered crucial for analysing disease pattern include “viral velocity” and “mortality rate.” When comparing with SARS and MERS viruses, the COVID-19 has been inferred to have 10% and 35% less mortality rate and 20 and 3 times less transmission rate than SARS and MERS as expressed in Table ​ Table3 3 (Adhikari et al. 2020 ; Baldo et al. 2016 ; Liu et al. 2020 ; MacIntyre 2014 ).

Comparative analysis of COVID-19 with previous flu outbreaks in terms of primary epidemiological parameters

Economic analysis

Analysis of the economic repercussions of previous epidemic events like SARS, MERS and the Spanish flu which has been recognized as pandemic similar to COVID-19 unfold important lessons. The socio-economic consequences included decreased the demand of goods and services, supply chain disruption, employment and income loss. However, in 2003 after the cases of SARS were controlled, a pronounced elevation in the demand rate was observed, and the same is expected at the end of this year if the COVID-19 spread is successfully controlled. Having said that, many economists express that in view of current uncertainty in disease control, it is very early to comment on the employment rate and demand and supply trajectory post-COVID-19 (Hassan et al. 2020 ).

The impact of environmental conditions on transmission and fatality rate of previous flu outbreaks has also been comparatively investigated. A similar trend was observed in terms of air pollution, as the urban centres have high concentration of positive cases in all previous flu outbreaks. Thus, a direct relation was inferred between disease spread and poor air quality which places the urban regions at high risk. The same drift has been observed in case of this recent pandemic as there is high fatality rate in megacities of China, the USA, Italy and Spain. To anticipate the macro-economic implications in view of previous pandemics, the decrease in GDP has been analysed, providing an average decline rate of about 10% post 1918 flu outbreak. The impact of COVID-19 on global GDP has been depicted in Fig.  2 ; however, the values reveal that the impacts are not of that adversity level until date, as observed in 2008–2009 fiscal crisis. The economically stable nations of the world are forecasted to encounter a GDP growth decrease of 7.8% including the USA, where the IMF has projected a decline of 5.9%. In the case of European countries, the GDP growth rate is forecasted to decrease by 7.5% while in developing countries with emerging economies a 2% decrease is anticipated. However, the economy in China, India, Pakistan and Indonesia will reflect an increase in GDP in the final quarter of 2020. It has also been inferred that the global fiscal deficits will require a long time to recover post-COVID-19 control. In the second quarter of 2021, a fragmental recovery period can be expected in GDP growth; however, that would be far below than the pre-pandemic rate (IMF 2020 ; OECD 2020 ; WEO 2020 ).

Percent variation in global GDP rate from 2005 to 2021

Although the modern viral strain does not appear to be as fatal in comparison to previous epidemics like SARS and MERS, it has become a global concern with drastically increasing transmission and fatality rate surpassing those of the pandemic of the previous century, i.e. Spanish flu in 1918–1919. At this point, accurately predicting the trajectory of the positive cases is not possible; however, the scale of socio-economic and geopolitical ramifications can be foreseen. The worldwide decreasing trend in petroleum, diesel and fuel oil prices owing to the cessation of industrial and transport activities has initiated a price war between the USA and Saudi Arabia. The lessons from the past epidemiological experiences should always be taken into consideration while devising better control mechanisms and mitigating the consequences of long-term economic destabilization (McKee and Stuckler 2020 ; Sharif et al. 2020 ).

Health system and response in Pakistan

Characterizing the ramifications of previously prevalent diseases on the public health care sector is quite convenient. However, projecting the scale of impacts of newly emerged viral or bacterial strains having unforeseen clinical impacts, transmission levels and mortality rates is often a strenuous task. In these circumstances, it is crucial to anticipate and manage the increasing health expenditures and relevant resources, not only during the disease outbreak but also for catering lasting post-disease costs (Stratford 2020 ; Junaidi 2020 ). Only 2% of the GDP in Pakistan is allocated for the public health sector, which is far below the worldwide average of 11.6% (WHO 2020a ).

As hospitals are inundating with COVID-19 patients and constantly pacifying fatality rates, Pakistan’s feeble health care sector is invigorating for an impending peak of cases. The country is rapidly taking measures for strengthening the public health system in order to effectively cope with the pace of pandemic spread. The important measures include establishing new laboratories and importing ventilators, testing kits and personal protective equipment for health professionals. The number of infected cases observed an exponential increase in May–July, surpassing China, the epicentre of COVID-19. Although the public sector representatives claimed that the condition of coronavirus spread is under manageable limits, the health care officials kept on pleading that within the existing financial and technical capacity, further increase in cases will result in collapse of the health sector (Agency 2020 ). Table ​ Table4 4 presents the province-wise statistics of medical and testing facilities available for coping with the pandemic in Pakistan.

Statistical analysis of the health care facilities for controlling COVID-19 in Pakistan

According to the report by the World Bank, Pakistan had a health care expenditure of 40$ per capita per year in 2016. On contrary to this, the neighbouring countries including India and Iran had relative figures of 62$ and 415$ per capita as depicted in Fig.  3 . Despite of allocating significant share of national budget for health care sector, Iran has encountered that severe clinical complications are managing the COVID-19 cases (Pakistan Today 2019 ; WHO 2020a ). This further adds to the concern of policymakers in Pakistan during such pandemics. Moreover, viewing the inadequacies of global health care systems, it is a deep concern for a country with such resource-constrained settings, to scale-up the disease detection and treatment facilities for efficiently and promptly addressing wide-reaching outbreaks of the deadly disease (IGC 2020 ).

Per capita expenditure of health by the government in Pakistan and its neighbouring countries

State of environment and pollution

The lockdown around the world has stifled the routine activities and has restricted many services including transportation, industrial and agricultural production which were attributed as major contributors to environmental pollution (Henriques 2020 ). While the disease outbreak has taken more than 1600 lives in Pakistan with accompanied negative ramifications impacting communities in the form of employment loss and financial breakdown, some positive impacts have been observed on the air quality. According to the World Air Quality report 2019, high air pollution levels were evaluated throughout the South Asian countries with Bangladesh, Pakistan and India ranking among the top five countries having worst air quality. However, over the last few months amid the coronavirus crisis, air quality across the world has reported considerable improvement as the major activities requiring immense fossil fuels burning have been halted to some extent (Pakistan Today 2020 ; Qazi 2020 ). Over the past few months during the lockdown period, the air quality data obtained from different major cities of Pakistan has reported considerable decrease in the concentration of primary air pollutants, e.g. NOx, SOx, CO 2 and PM 2.5 and PM 10 , while a gradual increase has been observed post lockdown. The air quality index level of four major cities from October 2019 to October 2020 has been presented in Table ​ Table5 5 (Abbasi 2020 ; CREA 2020 ; Pakistan Today 2020 ).

Variation in the air quality index of major cities of Pakistan from October 2019 to October 2020

An important initiative has also been taken by the Pakistan’s government for usefully indulging the labour and daily wagers that were not being able to continue their jobs owing to the lockdown and subsequent closure of various sectors. Some of these unemployed wagers have now been given employment opportunities as “jungle workers” in the 10 Billion Tree Tsunami programme, a plantation initiative of Pakistan. These types of “green or eco-friendly stimulus” human capital investments present an example of efficiently utilizing the monetary resources for helping the communities while proactively preparing the country to cope up with the next big threats ahead including climate change (WEF 2020 ). Nonetheless, such catastrophic events often result in proliferation in natural resources’ demand, leading towards high agricultural and wildlife harvest rates as the governments may overlook environmental protection policies while prioritizing economic stability post-COVID-19 outbreak (Pakistan Today 2020 ).

The impact of environmental conditions on transmission and fatality rate of previous flu outbreaks has also been comparatively investigated. A similar trend was observed in terms of air pollution, as the urban centres have high concentration of positive cases in all previous flu outbreaks. Thus, a direct relation was inferred between disease spread and poor air quality which places the urban regions at high risk. The same drift has been observed in case of this recent pandemic as there is high fatality rate in megacities of China, the USA, Italy and Spain (Di Gennaro et al. 2020 ).

Agriculture sector and food security

Many countries are experiencing a difficult time in protecting their agriculture sector from the adverse consequences of pandemic considering the potential threats of food insecurity. For developing countries, food security has always been a crucial subject (Imran 2020 ). In 2018, it has been estimated that 37% of the people in Pakistan are suffering from food insecurity issues. Sindh province, being the second largest agricultural producer in Pakistan, has 46% of population that lack access to basic nutritional facilities and is experiencing malnutrition issues including stunted growth (UNICEF 2018 ). In such critical scenarios, directing efforts to simultaneously address the disease spread and social protection are important.

The farming sector of Pakistan has not only served as a backbone for food security but has always been a major support to the economy, being the highest contributor to GDP. Pakistan is the 8th largest producer of wheat, 10th largest of rice, 5th of sugarcane and 4th largest producer of milk in the world. Even with this standing, only 63.1% of the population has adequate supply of food sources to be considered as “food secure” (UNICEF 2018 ). The agriculture sector in the country is facing various challenges including the recent pandemic which has disrupted the production by limiting the work force and restricting transport facilities for dispatching the harvested crops. Before the advent of this pandemic, the agriculture sector was sustaining the impact of wide-scale locust attack which has severely damaged various crops exerting economic stress on the associated farmers (Abid 2020 ; Ayra 2020 ; Imran 2020 ).

Grains and pulses

Wheat, being the staple food crop of Pakistan, is characterized in the group of 5 major export crops (cotton, wheat, rice, maize and sugar cane) that have a relative share of 4% in the GDP of the country. As most of the population depends on wheat and rice for basic nutritional needs, the impact of the current pandemic on their production levels needs to be analysed in terms of price fluctuations. Pulses occupying 5% of the total cultivated area are regarded as an economical source of vegetable proteins for the poor communities which cannot afford red meat or white meat for fulfilling protein requirements. Figure ​ Figure4 4 presents the variation in the prices of wheat, rice and pulses (masoor as it has the highest demand in the country). The price per 100 kg of wheat has been observed to be quite uniform until mid-June, but then a sudden increase has been observed. For pulses, a 24.7% decrease in price has been analysed. In the case of rice, initially a 6.6% increase in price has been observed, and after that, there is a declining trend until June, but again some increase has been seen in July (AIMS 2020 ; Anjum 2020 ).

Variation in the prices of wheat, rice and pulses per 100 kg in Pakistan from March 15, 2020, to July 25, 2020

Fruits and vegetables

Fruits and vegetables are usually at high risk in any agricultural crisis as these are perishable products having limited shelf life. Pakistan is one of the largest producers of mango with an annual yield of 1.7 million as of 2020. Mango is usually harvested in Sindh in the mid of May and in the first 2 weeks of June in Punjab. The primary concern this year was the unavailability of workers for harvesting the ripened fruit. The second major issue was limited means of transportation for transferring the harvested products into the retail markets for their domestic sale amid lockdown. This also impacted the export market as the exchange of goods between countries was temporarily suspended. The price variations per 100 kg are analysed from March 15 (the start of lockdown in Pakistan) to July 25, 2020, for 3 major vegetables, i.e. tomato, potato and onion, and 2 fruit types, i.e. apple and banana, as presented in Fig.  5 . Those fruits and vegetables types are selected which show least seasonal production level fluctuation in these specified months (Abid 2020 ; AIMS 2020 ; Dawn News 2020 ).

Variations in prices of major vegetables and fruits in Pakistan from March 15 2020, to July 25, 2020. a Variations in prices of three major vegetables in Pakistan from March 15, 2020, to July 25, 2020. b Variations in prices of major fruits in Pakistan from March 15, 2020 to July 25, 2020

Poverty and labour market

For a developing country which is already struggling at the societal and economic front, a wide-reaching pandemic like COVID-19 can further elevate the poverty level as unemployment and income deficit increases. The poverty and unemployment impact level can be viewed in terms of three relative GDP growth scenarios: high recession, i.e. 0–1.5% increase in GDP growth, medium recession, i.e. 1.5 to 2.5% decline in GDP rate, and low recession, i.e. 2.5 to 3.5% decrease in growth rate. It has been projected that the employment level in Pakistan will decrease from the baseline level of 3.86 million to 0.21 million (low economic recession scenario) reaching 0.62 million (high economic recession scenario) due the recent pandemic. Moreover, 33.7% increase in poverty level has been expected from the baseline value of 23.4% in case of low recession scenario, while a 44.2% and 58.6% elevation has been estimated in case of medium and high economic recession, as represented in Fig.  6 (ILO 2020b ; Labour Force Survey 2018 ; Mamun and Ullah 2020 ). In addition to the poverty hike, a significant increase in the venerable population is also expected in Pakistan. This population include human communities earning income sufficient enough to keep them slightly above the poverty line, and longer periods of national economic instability will ultimately result in pushing them below the poverty line.

Poverty rates at different economic recession scenarios in Pakistan

Employment layoffs

In this period of epidemiological and socio-economic crisis, effectively channelling the priority measures is a challenging task particularly for low-income developing countries like Pakistan. In the case of labour community, it has been crucial to choose between reduced disease exposure and financial stress. COVID-19-induced labour market backlash can be attributed to three major aspects including the decline in the number of employment opportunities owing to the closure of various state sectors. The second aspect can be described as the qualitative decline in employment type in terms of the absence of additional benefits or relief schemes in case of health problems or any other stress which is usually termed as social protection. The third aspect is the disproportionate influence on vulnerable sectors of the market which include the old-aged, women or people with physical impairments and small-scale private earners (ILO 2020a ).

It is challenging for micro-enterprises that dominate the business sector in Pakistan to observe compliance with the standard operating procedures (SOPs) encapsulated by the government to ensure workers’ protection. As a result, most of these enterprises have permanently suspended their employees after the lockdown. According to 2017 census, the total population of Pakistan was declared as 207 million and out of this, 20 million (i.e. 10%) constitutes of people over the age of 50. Out of this 20 million, approximately 9 million are part of the labour force. The total labour community in the country is around 63 million (mostly of the age of 15 and above), and 6% of these have already lost their employment. The restaurants, hospitality sector, education institutes, small retail markets and the transport industry can be considered as the most adversely impacted sectors by the pandemic. Nearly 7.15 million workers are directly associated with these worst-affected sectors as per the Labour Force Survey ( 2018 ) (Ahmad 2020 ; Labour Force Survey 2018 ).

All the countries around the globe ceased the routine activities and services as an attempt to limit the mobility of people and thus preventing disease exposure. Lockdown has been considered as the only way of controlling the disease spread while flattening the virus escalation curve. As a result, in Pakistan the government also announced complete lockdown from March 23 to May 9, 2020, involving various sectors including educational institutes, businesses and public transport in all the provinces. As per the government guidelines, people employed in formal sector enjoyed job security and were also being paid during this lockdown, but those associated with informal sector had no access to all these benefits, and most of them were suspended (Malik et al. 2020 ). From the global instances, it was analysed that the daily wagers, street vendors, domestic helpers, people involved in courier and delivery services, cleaners and waste collection personnel possess the maximum disease exposure risk. The informal work force encountered joint issues of coronavirus infection and economic stress resulting in deprivation of food and daily necessities (Coibion et al. 2020 ; Inoue and Todo 2020 ).

Understanding the socio-economic consequences of different levels of social distancing and various stages of lockdown is crucial at the moment for devising efficient control measures. There are three basic stages of social distancing, i.e. stage I including limited restrictions, stage II which includes medium level of restrictions where major sectors are closed while some are still operational and stage III that includes complete shutdown of activities and total restriction on public movement. Table ​ Table6 6 characterizes the evaluated employment layoffs in different important sectors at the three major stages of social restrictions. At stage I, agriculture sector has almost no visible impact, while in stages II and III noticeable impact has been observed owing to the decrease in local and international demand. The worst impacted sectors during stage II lockdown include retail markets, transportation and manufacturing industry, major reason being the high ratio of vulnerable employees (informal workers). Shift from stage II to stage III is estimated to increase the layoffs by 10 folds (Nasir et al. 2020 ).

Sectoral employment layoffs at different stages of lockdown and social distancing

It is also important to anticipate the provincial scale of impact on vulnerable employees in various sectors for affectively developing relief packages for individual provinces depending on the potential layoffs as depicted in Table ​ Table7. 7 . Being the province with maximum population, Punjab has the highest number of work force including the vulnerably employed and thus requires sufficient relief funds to support these people. Pakistan had announced nationwide lockdown of somewhere between stages I and II in the end of March 2020 when the number of infected cases was rapidly increasing. This resulted in widespread economic pressure on the poor communities which were solely dependent on their daily wages for food. Viewing these adverse consequences, the government later decided to ease the lockdown on May 9, 2020, and gradually opened some employment sectors despite spiking COVID-19 cases. Another social distancing strategy which is currently in practice termed as “smart lockdown” has been developed. This involves identifying the COVID-19 hotspots and restricting activities in those identified areas. The trend of new coronavirus cases is being regularly monitored and if the situation deteriorates, new control measures will be introduced (Ahmad 2020 ; Faraz and Nasir 2020b ).

Province-wise sectoral employment layoffs for vulnerable employees in Pakistan

Socio-economic impacts

Around the world, the regulatory agencies have apprehended lately that the biological threats not only impact the environmental health but also pose abiding wide-scale impedance in socio-economic parameters (OECD 2020 ). The impacts of such epidemic events on diverse state sectors, particularly those directly contributing towards the economic stability, are usually unseen instantly, but they lead to long-term adverse consequences. Such repercussions dominate the entire industrial arena with deep-routed consequences on local supply chains and national markets as the risk of health loss creates a sense of insecurity among masses (Duffin 2020 ; Nicola et al. 2020 ).

Education sector

Around the world, approximately 2.2 billion students are battling against COVID-19 and have been constrained to temporarily discontinue their formal education. The government of Pakistan has also suspended the formal academic activities and has provisionally shifted to virtual learning systems as an attempt for containment of coronavirus, controlling its wide-scale transmission. This transition towards virtual education necessitates timely large-scale allocation of resources for catering the academic requirements of approximately 47 million (according to the figures of year 2018) students which have discontinued their formal education (Fig.  7 ) (Ahsan 2020 ; Hyder 2020 ; Siddiqi 2020 ). This situation has resulted in increased drop-out rates as some small-scale educational institutions permanently ceased their activities due to shortage of funds.

Number of students affected by the COVID-19-induced closure of educational institutions in Pakistan (Hyder 2020 )

With the dominance of virtual learning systems, the issue of digital divide raises concerns particularly in less technologically privileged countries like Pakistan where only 22% of the population have access to internet facilities. Most of the population especially those living in rural settings lack access to modern ICT equipment and internet connections. It is estimated that only 16% of the total population of Pakistan use smartphones having internet access while 53% people are using conventional mobile phones with basic features which lack internet connectivity options (as per the statistics of 2018). This is usually attributed to high poverty ratio and lack of technology infrastructure which limit the access of high-end internet facilities and ICT equipment to students living in urban or semi-urban regions and usually belonging to middle and upper societal classes (Hyder 2020 ; Saeed 2020 ). The country has now shifted to hybrid system of education as educational institutions are being opened in phases where both online and classroom teaching are being practiced in an attempt to curb the spread of the virus and prevent an anticipated spike.

Tourism industry

The travel and tourism industry can be regarded as one of the worst impacted sectors by the current pandemic. As depicted in the Fig.  8 , the United Nations World Tourism Organization (UNWTO) has estimated that the tourists count will decrease by 20 to 40% in the present year, accounting for a loss of approximately 350 to 450$ billion in international tourism revenue (UNWTO 2020 ). The virus outbreak and consequent lockdown has not only directly impacted in terms of tourism-based exports’ decline but will also create lasting contagion effects on the economic stability of any country. Moreover, thousands of people which are dependent for their livelihood on the tourism industry are now exploring other means of earning their basic needs. Thus, it can be implied that even when the COVID-19 is controlled, recovery from the deep-routed multi-sectoral ramifications will be a strenuous and time-consuming task (Ali 2020 ).

Number of international tourists worldwide from 2015 to 2020

In Pakistan, the tourism industry was enjoying its peak during the last year as also expressed in the international reports of Conde Nast and Forbes , where the country was ranked as one of the top tourism destinations in 2020. It was anticipated that this year in the months of March and April, Pakistan will receive the highest number of international tourists, indicating significant economic uplifts. However, the unexpected outbreak of this novel viral disease has changed the entire course (Hussain 2020 ). The recent lockdown and rising COVID-19 cases in Pakistan have already curtailed the domestic travelling trend by 60–70% (PTDC 2020 ). In another report by Asian Development Bank (ADB), it has been estimated that Pakistan’s struggling tourism sector is likely to encounter an economic loss of approximately 6 million US$ in 2020, based on the worst projections of expected cases.

Trade and GDP

As per the early estimations, this pandemic would result in a global economic recession of nearly 9 trillion US$ in 2020–2021 fiscal year (Ahmed 2020 ). In the fiscal year (FY) 2019, the total GDP of Pakistan was calculated to be 38.6 trillion PKR at a growth rate of about 3.3%. It was being anticipated that in the financial year 2020, the economic growth rate will decline to 2.6% (Haider 2020a , b ; Nakhoda 2020a , b ). The present-day estimations reported by Planning Commission of Pakistan predict an economic loss of about 10%, i.e. 1.1 trillion PKR in the FY 2021 (World Bank 2020 ; Mustafa 2020 ). The impacted economic sectors in Pakistan are presented in Table ​ Table8 8 .

Production and economic loss in various sectors of the society due to COVID-19 outbreak in Pakistan

Eight large financial capitals of the world, contributing about 45% to the global GDP and primary export partners of Pakistan having share of 40% in country’s foreign revenue, are facing appalling economic pressure including the USA, the UK, Germany, France, Spain, Italy, Japan and Canada. All these countries have been at the worst hit by the recent pandemic which calls for adverse ramifications on Pakistan’s foreign revenue (Ashraf 2020 ; Faraz and Nasir 2020b ; ITC 2020 ).

The trade pattern with four major partner countries including the USA, the UK, China and Germany has been depicted in Fig.  9 . The data is collected over a period of 11 months from August 2019 to April 2020 so as to examine the pre- and post-COVID-19 scenario. It can be observed that in the case of the USA, the UK and Germany, there is a positive economic trend until February 2020 which can be attributed to their prevention from the COVID-19 outbreak, but the import and export flows with Pakistan have been analysed to depict a declining trend after March. In the case of China, the data for the month of February is unavailable due to the international trade ban, which was lifted in mid of March. As China has successfully controlled the pandemic, their economy is now enjoying a period of resurrection. During the spike of COVID-19 cases in China, i.e. in the month of February, Pakistan’s export with other trade partners has increased drastically. With the current level of uncertainty in disease spread, accurate anticipation of future trends in the trading market is not practically possible. However, if the COVID-19 cases continue to increase with the same rate, restrictions in the industrial production, supply chain disruption and limited domestic and international transportation will deteriorate the economic structure of many developed countries of the world (Ashraf 2020 ; Faraz and Nasir 2020a ; ITC 2020 ; Nakhoda 2020a , b ).

Percent change in the import and export flow of Pakistan from August 2019 to June 2020. a Variations in the flow of exports and imports between Pakistan and the USA from August 2019 to June 2020. b Variations in the flow of exports and imports between Pakistan and the UK from August 2019 to June 2020. c Variations in the flow of exports and imports between Pakistan and China from August 2019 to June 2020. d Variations in the flow of exports and imports between Pakistan and Germany from August 2019 to June 2020

COVID-19: measures and lessons

Containment measures.

Almost all the countries of the Asia-Pacific have taken measures for the containment and/or mitigation of the spread of COVID-19. These included declaring a state of emergency, putting the country or major cities under lockdown or curfew. Measures were taken to lower the risk of importing the virus through (a) full or partial closure of borders, (b) carrying out passenger screening at the airports (c) and introduction of travel restrictions or bans. Measures have also been taken to contain community transmission through (a) social distancing; (b) closing schools, colleges and universities; and (c) closing public places (Ocampo and Yamagishi 2020 ). However, only a few countries imposed fines or punishment for violating such isolation orders For example, Singapore penalized its citizens with a fine of up to S$10,000 or 6 months of imprisonment if anyone flouted the regulations. In contrary, only a quarter of the countries are mass testing the virus and are also tracing the potential contact which have been identified to be effective measures in containing the virus (The Guardian 2020 ).

Macroeconomic stimulus

Certain fiscal measures have been taken by the countries to save lives and livelihoods through stimulus packages so that the adverse socio-economic impact can be reduced. Countries have mainly prioritized their support to the health workers and paramedic staff. Measures are being taken to support businesses especially small- and medium-sized enterprises (SMEs). Furthermore, global and regional corporation is being engaged to combat COVID-19. Countries like Australia, Azerbaijan and New Zealand are contributing to the World Health Organization (WHO) fund. Japan has extended monetary support to the International Monetary Fund (IMF). These fiscal stimulus packages vary in size from country to country, ranging from 0.1 to 20% and more of GDP. Countries of the Asia-Pacific have also taken some monetary policy measures to avoid liquidity and credit crunch. Such measures are taken to complement the fiscal policy measures so that financial stability could be strengthened (IMF 2020 ). Countries are actively supporting their financial markets through reduction of debt burden on SMEs such as loan deferment, extensions and moratoriums are being allowed. The volatility of stock market is being eased through the temporary prohibition of short-selling, and reduction or exemption of fees for securities services (UNESCAP 2020 ; Xia et al. 2020 ).

Conclusions and the way forward

With the advent of novel super-contagious viral strain, the health sector around the globe has undergone significant developments not only at the treatment side but also at the disease prevention end. A similar trend is being observed in Pakistan too, where the public health system is mobilizing the relevant national instruments to deter rapid transmission rates of the recent pandemic. The regulatory agencies have apprehended lately that biological threats not only impact the environmental health but also pose abiding wide-scale impedance in socio-economic parameters. This necessitates comprehensive decision-making and directed efforts including multi-sectoral analysis of the negative externalities apart from the apparent human health-centred measures. This study has illustrated the short- and long-term prospects of the pandemic on the emerging economy, society and the environment in view of the current discussions. The COVID-19 outbreak and consequential lockdown have negatively impacted the GDP growth in Pakistan, i.e. lowering it from 33.2 to 2.2%, while the global GDP growth rate is expected to decline from 3.1 to 2.8%. The issues like local disruption of supply chains and national markets, poverty hike, employment layoffs, discontinuity of formal education of 47 million students and increased food prices are critical predominant challenges for the Government of Pakistan. On the other hand, drastic improvements in air quality index have been observed around the world including urban centres of Pakistan as a result of restricted transportation and industrial and agricultural activities which are attributed as major contributors of environmental pollution. This has helped in identifying the hotspots and activities which are major contributors towards environmental deterioration. Nevertheless, long-term environmental consequences in the form of increased burden on natural resources and over-exploitation may appear in future.

Many of the developing as well as developed countries having modernized and stable economic and health care sectors have drastically failed to limit the number of infected COVID cases as they might be lacking in-terms of timely prevention-planning and decision making. This has called for immediate need for Pakistan to learn lessons by identifying the loopholes in the measures taken by other countries and response of public authorities after initial failures have marked as unsatisfactory by the WHO, etc. This pandemic however has become a test case for Pakistan and the rest of the world for improving the preparedness and response mechanisms towards such pandemics. Greater mandates for planning, management, surveillance-monitoring, tracking-tracing, timely scientific advisories and responses to infectious disease outbreaks, accompanied by a substantial increase in global funding, are highly desirable. As the country is now approaching towards second wave of the pandemic, the core task is to widen the access to information and data which were not available previously to decisionmakers while dealing with the first wave. The virus status in the country is currently at a particular point in time where sequenced measures can significantly aid in controlling the spread unlike in the first wave, when welfare interventions had not been designed before time.

The way forward

In such unprecedented times, there is a dire need to develop economic recovery policies which have been embedded with inclusivity and sustainability. The policy packages which have been announced so far differ from country to country in terms of their aims. Some have prioritized their health sector to relieve its burden and are also dealing with the adverse impacts their economies are facing. On the other hand, some countries have decided to reopen their economies.

It is still very early to judge the effectiveness of these policies since there is a possibility lingering upon us that we might face another wave(s) of COVID-19. Apparently, the pro-active actions and timely decisions have helped to suppress the virus and to support small- and medium-scale businesses along with households to help save their lives and livelihoods. Another key aspect to be considered by decision-makers is that economic policy packages should be inclusive and sustainable.

Although the announcement of fiscal stimulus packages by countries have proven to be very helpful, but it will be more effective when resilience and preparedness is built in the community. As the current pandemic has clearly exposed the fragility of our economic, health and emergency preparedness systems so for future anticipations, to manage the crisis and lowering of impacts, it is important to strengthen social protection since it will act as an automatic stabilizer to help protect most vulnerable people.

The developing countries like Pakistan need to focus more objectively on the prevention is better than cure philosophy, and this is the right time to think proactively and keep them ready for any similar shocks in future. As their economies are already stressed and facing critical challenges due to their weaker political structure, limited fiscal space and capital markets, so they cannot afford to roll out the effective and timely stimulus packages like many developed countries.

South Asian region is facing an extreme climate emergency. Policy responses which are being taken to combat COVID-19 must simultaneously be assistive towards the acceleration of low-carbon transition, thereby supporting the climate change mitigation efforts. For instance, as the oil and gas prices are currently low, it can provide an opportunity for the implementation of broader carbon pricing mechanisms and the elimination of subsidies on fossil fuels.

Business sectors and their sound performance always play an integral role for the strengthening of any economy because of generations of monetary capitals and livelihoods. However, the firms and businesses must be made environmentally and socially responsible in terms of corporate social responsibility (CSR). They should provide their workers with decent living wages and other related benefits, and negative environmental externalities due to business operations should be internalized. As such a firm-wide three factors strategy, i.e., environmental, social and governance (ESG), will lead to increased transparency, responsibility and higher standards of reporting.

This current pandemic has helped us to realize that we cannot simply continue to consume our way, but we need to adopt sustainable lifestyles. During the essential lockdowns and isolation policies, the supply of goods and services have been reduced to only essentials, and people are able to differentiate between their needs and wants. Therefore, there should be an individual realization and adaptation of a sustainable lifestyle that will minimize the use of natural resources, consequently reducing our carbon footprints. The governments and firms can promote such sustainable goods, services and lifestyles by market-based instruments like voluntary ISO standards and eco-labelling.

This pandemic has emerged at a time where global cooperation was limited, but now this influential shock has taught the world about constructive exchange of ideas, cooperation and reaching the multitude of mutual solutions, which are imposable otherwise at their individual capacities. For example, in 2003 when the outbreak of severe acute respiratory syndrome (SARS) occurred, it taught us that information should be shared, responses should be coordinated and resources such as personal protective equipment, medicines and testing kits should be pooled.

The need of the hour is that global community should join hands to develop vaccines and medicines and to lift trade and tariff barriers especially on the medical equipment and supplies. Countries should also coordinate their fiscal and monetary policies along with concerted efforts to help indebted nations for the creation of fiscal space to help them mitigate the pandemic and to ensure their economic recovery, such that no one is left behind.

Authors’ contributions

Rizwan Rasheed: Conceptualization, visualization and methodology

Asfra Rizwan: Data curation, writing and formal analysis

Hajra Javed: Writing and original draft preparation

Faiza Sharif: Supervision and review of results

Asghar Zaidi: Administration, reviewing and editing

Data availability

Compliance with ethical standards.

The authors declare that they have no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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