DEMOGRAPHIC CHARACTERISTICS

Globally, Pakistan is the fifth most populous country: the total population is approximately 212.82 million.⁵ According to the Pakistan Demographic and Health Survey 2017-18, around 10% (of the sample size) of households lack water, soap, or other appropriate cleaning agents in place for handwashing.⁶ Footnote * Around 30% have no appropriate sanitation facility that is not shared with other households,Footnote ^† and merely 25% have flush toilets linked to a septic tank.⁶ Fifty percent of women have no education compared with 34% of men, and net (school) attendance ratio (NAR) is 59% at the primary level and 38% at the middle/secondary level.⁶

HEALTH-CARE SYSTEM: SERVICES, PROVIDERS, AND DISEASES

According to the Economic Survey of Pakistan 2018-19, Pakistan has approximately 1300 public sector hospitals, 5530 Basic Health Units (BHUs), 700 Rural Health Centers (RHCs), and 5680 dispensaries.⁵ The following was the ratios: 1 doctor per around 970 people, 1 dentist for around 9450, and 1 hospital bed for 1610 people.⁵ In terms of the provision of health care, rural and urban areas of the country report a large difference. Urban areas have enough and more proper facilities than rural populations.

In addition, several infectious diseases are prevailing in the country: eg, HIV/AIDs, hepatitis, measles, and polio. Witnessing around 8 outbreaks of HIV since 2003, Pakistan has been declared the second-fastest HIV growing country across Asia.⁷ Approximately 80% of the world’s hepatitis patients live in Egypt and Pakistan: of which approximately 18 million people have been infected with hepatitis in Pakistan.^{Reference Ali, Donahue and Qureshi8,Reference Ashraf and Ahmad9} Pakistan is in the top 10 countries for the highest absolute number of neglected tropical diseases (NTDs) infections.^{Reference Blum, Majid and Hotez10} In 2013, one study found that around 80 million individuals suffered from 1 or more chronic conditions, such as cardiovascular diseases, cancers, respiratory diseases, diabetes, and mental disorders.^{Reference Jafar, Haaland and Rahman11} Measles has infected around 7000 children in 2019, and it caused a severe outbreak in 2012-13 infecting thousands of deaths and causing hundreds of deaths.^{12,Reference Ali13} Besides, Afghanistan, poliovirus is still prevalent in Pakistan.¹²

Moreover, malnutrition in the country is a great concern: 38% of children are “stunted” (short for their age), 7% are “wasted” (thin for their height), and 3% are overweight (heavy for their height).⁶ The next most vulnerable group for malnutrition is women.^{Reference Iqbal, Rust and Weitensfelder14,Reference Iqbal, Ali and Rust15} The percentage of malnutrition, food insecurity, and hunger increases in rural areas, especially in Thar Desert of Sindh province.

ECONOMIC INEQUALITIES AND PERSISTENT CORRUPTION

Economic disparities are prominent in Pakistan. Around 25% of the country’s population lives below the poverty line (earning the US$2 per day).⁵ For gender and geographical area, these differences further intensify. The female population and people settled in rural areas fall into the lowest wealth quantiles.⁶ For gender related-inequalities, Pakistan was at 133 on the Gender Inequality Index (GII) in 2017.⁵

Like many South Asian countries, widespread government corruption is continuing in the country: According to Transparency International in its Corruption Perception Index for 2019, the country stands at 120th out of 180 countries.¹⁶ This organization indicated an increase in corruption compared with 2018. Endemic corruption has impeded economic growth, ultimately leading toward a weaker country that cannot successfully face a challenge or emergency on its own.^{Reference Khan17,Reference Farooq, Shahbaz and Arouri18}

SOCIO-CULTURAL FACTORS CONCERNING HEALTH CARE

A substantial number of people regard health and illness as an act of God. Keeping someone healthy, making someone ill, and recovering are believed to be predetermined.^{Reference Ali19,Reference Ali20} This perception may lead people to be less careful about preventive measures about COVID-19. During the ongoing pandemic, the media have repetitively reported that people are congregating, arranging marriages, and performing religious festivals.

Moreover, living together, especially in a joint and extended family in rural areas, is a highly valued cultural norm. Three and in some cases, 4 generations live together, sharing their spaces and coming into frequent body contact.^{Reference Ali19,Reference Ali20} Countrywide, the following average household was reported by a survey: urban 6.3 and rural 6.8.⁶ In rural areas, there are clusters of houses, locally called Mohalla or Parro, with 1 boundary wall.^{Reference Ali19} Each cluster may consist of around or over 100 individuals.

Many people, particularly living in rural areas, do not merely subsist on animals, they also share their living spaces with them.^{Reference Ali19} Economically marginal people often share spaces with their cattle, sleeping in the same place at night. These people do not consider cattle, including their feces, as unhygienic or harmful to health. They dry dung and use it as a fuel for cooking food. It is primarily landless or small landowners in rural areas who significantly subsist on livestock.²¹ According to 1 report, livestock is considered as a “secure” source of livelihood for the people of Thar.²² An often-used expression is, “Thar depends upon animals, not crops,” and another expression reads, “a poor man [person] was 1 who owned no cattle or goat.”^{Reference Herani, Pervez and Rajar23} These expressions illuminate the importance of animals for the inhabitants and the human-animal relationship. In contrast, studies have revealed about the transmission of vectors from animals to humans.^{Reference Swartz24} Annually, zoonoses cause morbidity in billions and mortality in millions in humans.^{Reference Health Organization25} Due to this effect, zoonotic diseases have become a significant public health concern, eg, COVID-19.^{Reference Rothan and Byrareddy26} Nevertheless, these animal-dependent people have no or little choice about their level of proximity with their animals.

Furthermore, like handshaking and hugging, eating with hands are appropriate cultural norms, in part due to cultural mores but also to the fact that about 25% of the population lives under the poverty line and cannot afford the required cutlery. Not engaging in these behaviors is normatively regarded as highly inappropriate and unethical. Of course, these cultural norms also supply vectors for disease transmission, and they are changing in response.

Several rumors and conspiracy theories prevail in the country, particularly about vaccination programs.^{Reference Ali4,Reference Ali13,Reference Ali19,Reference Ali27} There are several speculations about the “hidden” interests of vaccination campaigns, eg, a “Western” plot to sterilize Muslim women, and potential “side-effects” of vaccines that may kill children.^{Reference Ali4,Reference Ali13,Reference Ali19,Reference Ali27} Although suspicion about vaccination has not spilled over into suspicion about COVID-19, thus far, there are various competing narratives with unknown and untraceable sources, which have emerged, specifically in the villages (Salma, Ali and Ali, unpublished). Stories have surfaced to trace a “hidden” agent: the pandemic is “bioengineered” either by the United States or by “Big Pharma.” Speculations also contain home remedies, such as drinking garlic water (which might help), or “blowing hot air from a hairdryer through your nostrils,”^{Reference Imran28} or “killing” the infected people, “shaving one’s head,” and the “miraculous” birth of an infant.^{Reference Ali13,Reference Ali19,29-Reference Ali and Rezaei31}

GOVERNMENT RESPONSE TO THE COVID-19 PANDEMIC

To contain this virus, Pakistan has implemented several measures. After cases of COVID-19 in China, Pakistan suspended flights to China, then to Iran, Qatar, and Italy.^{Reference Imran28} In the beginning, the country sent the specimen to China and the United States due to the unavailability of test kits in the country, and later on, imported 1000 kits from China.^{Reference Imran28} On March 13, when the virus infected around 30 people, the government closed educational institutions, shut the border with Afghanistan and Iran, and opened a quarantine camp at Pak-Iran border.^{Reference Imran28,Reference Ali and Rezaei31,Reference Khan32} Afterward, the country banned congregations, including conferences and gatherings.^{Reference Imran28,Reference Ali and Rezaei31,Reference Khan32} On March 17, the country’s Prime Minister ruled out the option of lockdown while considering that 97% of patients recover.³³ Nonetheless, Sindh province already implemented the lockdown. Later, the country went into lockdown and opened more quarantine centers.^{Reference Imran28} Police and army were being deployed across the country, including booking the “violators” under Section 188 of the Pakistan Penal Code: the penalty includes 6 mo in prison or fine or both.^{Reference Imran28}

Furthermore, the government also created a Corona Relief Tiger Force to make people aware of the severity of COVID-19 and the importance of following standard operating procedures (SOPs).^{Reference Imran28} Although the government has distributed food items among daily wage laborers, people have criticized this distribution not just because of the number but also due to being photographed (with selfies) and shared on social media.

On May 9, 2020, the government lifted the countrywide lockdown. The Prime Minister argued that the “elites” want to extend the lockdown as they have “spacious homes” and sufficient income; thus, they would not be affected by the fallout of the measure.²⁹

Given that, while considering it as the “pioneering” initiative, the country has changed lockdown into a “smart” lockdown.^{Reference Ali, Sadique and Ali34,Reference Health Organization35} By that, the government means to place virus hotspots under lockdown.^{Reference Imran28} For instance, the “15-d smart lockdown” ended in 7 cities of Punjab province while this lockdown has been extended in many parts of Lahore city. Under this lockdown, educational and training institutions, restaurants (except take away), marriage halls, cinemas, business centers will remain shut. Sporting, social, and religious events are also banned.

A WAY OF CONCLUSION

By the time we are writing this artice (July 2020), the virus is steadily spreading in Pakistan, and has already overwhelmed the country due to its critical state of socio-cultural, economic, and political systems. The above-discussed forms of inequalities—related to demographic landscape, economic patterns, health-care system, political landscape, and socio-cultural features—characterize it as a vulnerable county to COVID-19, including other similar overwhelming events that require a prompt and resourceful response.

The virus has not spared high-income countries from significant effects; hence, dealing inappropriately with it may overwhelm low-income countries like Pakistan. The virus may exert unbearable consequences on Pakistan’s socio-cultural patterns, economy, and health-care system, including the emotional and mental health of people.

It is, therefore, suggested that these low-income countries may make short- as well as long-term measures in advance. Short-term, the country may take appropriate and possibly effective measures to halt or slow the transmission of the virus and minimize its overwhelming effects at an individual and institutional level. They may learn lessons from high-income countries with effective health-care systems, low-population, good hygienic practices, and different socio-cultural patterns, which have substantially suffered.

Long-term measures may include devising and implementing those policies, which minimize the rising disparities and inequalities. Specifically for Pakistan, it is important to bring that 25% of the total population above the poverty line, so that they may not always stay on the verge of danger. The efforts may address the growing sociocultural, economic, and political inequalities. Among other probable solutions, the focus may be on the quantity and quality of education, as well as health, infrastructure, and employment. Yet rural areas need considerable attention with regard to it, because the difference between rural and urban areas should be minimized.