Mass Gatherings – Neglected Factor In COVID Surges Seen In India, Pakistan and Neighbours Health Systems 28/04/2021 • Rahul Basharat Rajput & Mohammed Nadeem Chaudhry Share this:Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Facebook (Opens in new window)Click to email this to a friend (Opens in new window)Click to print (Opens in new window) Tens of millions of Hindu worshippers gathered in April to celebrate the Kumbh Mela festival in India – a factor believed to have contributed to a massive surge COVID-19 cases. ISLAMABAD, PAKISTAN – Pakistan and its three estranged neighbouring countries – India, Iran and Afghanistan – are all struggling to restrain their large populations from attending deeply rooted and centuries-old cultural, religious festivals – so as to curb the spread of COVID-19 in the region. The cultural, political, and religious gatherings in all four developing countries have emerged as a major challenge for governments as people continue celebrating festivals with cultural and religious zeal and zest. The four countries share common borders with porous passages through rural and mountain areas where the virus can easily pass, regardless of official restrictions or closures in place. With a cumulative population of 1.69 billion, the four countries have recorded a total of 21.2 million COVID-19 cases and 291,847 deaths since the beginning of the pandemic. India is currently facing a catastrophic second wave, accounting for 38% of global cases reported in the past week, according to the World Health Organization (WHO). However, important, although lesser noticed surges of varying degrees also are occurring in neighbouring Iran, Pakistan and Afghanistan – with new cases daily in Iran per million population approaching Indian levels. And those, too, appear heavily linked to the season’s ritual mass gatherings, health experts and authorities told Health Policy Watch in an exclusive set of interviews. The events include the recent “Nowruz” New Year celebrated in Iran and parts of Afghanistan, the ongoing Islamic month of Ramadan, and the February-April Hindu celebrations of Kumbh Mela, where pilgrims dip in the Ganges in what has been described as the largest religious gathering in the world. Whatever their national affiliations, health experts from Pakistan, India and Iran believe that the situation in the region will deteriorate further if human interaction is not more controlled. WHO has noted the lack of compliance to public health measures, low vaccination rates, and mass gatherings have combined to cause a “perfect storm” in the case of India’s surge. However so far WHO’s public messages have fallen short of specifically calling out the mass gatherings, related to sensitive cultural and religious moments, as a key cause of the rising case loads – even though health officials privately say that this may be one of the biggest drivers both in India as well as throughout the region. “The extent to which these virus changes are responsible for the rapid increase in cases in the country remains unclear, as there are other factors such as recent large gatherings that may have contributed to the rise,” said Tarik Jašarević, WHO spokesperson at a press briefing Tuesday. Hindu & Muslim Holidays Have Seen Surge of Mass Gatherings Hindu celebrations of Kumbh Mela, where pilgrims dip in the Ganges, drew millions together. As around 25 million people gathered on the banks of river Ganges in India to celebrate the Hindu festival of Kumbh, which runs from February to late April, people in Iran and northern areas of Afghanistan were preparing for, and celebrating ‘Nowruz’ festival (New Year) over the latter two weeks of March. Meanwhile, the holy month of Ramadan, which began on 12 April, is in full swing for Muslims across the region, which is marked by daytime fasting but evening break-fast and social gatherings. Pakistani health authorities are trying to toe a strict line, but they fear that over the even more intensive gatherings that mark the end of Ramadan and Eid-al-Fitr holiday, the country could see a further rise in cases, especially if the public doesn’t comply with the national Standard Operating Procedures (SOPs) for COVID-19. Pakistan, India and Iran imposed partial lockdowns over the past two weeks in an attempt to curb transmission in the worst affected cities. However adherence to the restrictions has been mixed – and government leadership in some instances has also been wanting – for instance in India where State election campaigns have also seen big mass gatherings organised by the government’s leading political parties. According to Dr Zafar Mirza, a former high-ranking official in the WHO Office for the Eastern Mediterranean Region, which covers Pakistan, Iran and Afghanistan, human interaction at religious, cultural and political gatherings in Pakistan, India and Iran have indeed contributed to the regional rise in cases. <402> An unfortunate day in 🇵🇰 – 201 deaths due to COVID-19 in 24 hours. This is a maximum number of deaths in a day since the beginning of the disease. If we act responsibly we can prevent and minimise this loss. But people are still not observing SOPs!! Very unfortunate. pic.twitter.com/0J6BmpbtiP — Zafar Mirza (@zfrmrza) April 28, 2021 The only real solution to the virus is immunity – either acquired from natural infection or vaccines, stressed Mirza. Accessing COVID-19 vaccines, however, has been a challenge for low- and middle-income countries, as high-income countries “over-booked” the available vaccines through bilateral deals with pharma companies. This has left low- and middle-income countries with two equally difficult choices: “Either develop their own vaccine and end their 100% vaccine import dependency or strictly follow COVID-19 SOPs, minimizing the human interaction to save maximum lives,” said Mirza. Mirza feared that if human proximity is not controlled throughout the region, there is a high chance that the dire situation being seen in India could further deteriorate. Pakistan Takes Steps to Enforce Domestic Restrictions Eying with worry developments among neighbours, Pakistan’s government has recently further tightened COVID-19 restrictions, and even deployed army troops to help the civil administration with their implementation during the latter half of Ramdan. The country’s Interior Minister, Sheikh Rashid Ahmed, announced that the ministry issued a notification enabling provincial governments and federal territories to seek the help of the army to enforce standard operating procedures for curbing the spread of the coronavirus. The government’s moves have received strong backing from the Chairman of the Council of Islamic Ideology (CII) in Pakistan, Qibla Ayaz, said in a press briefing that the third wave of COVID-19 was more dangerous than the previous two and the religious segments of society had a serious responsibility to follow the precautionary SOPs and spread the message among the citizens. He said in the press briefing that prayers can be performed at home and the public needs to adapt some of its traditional practices, as recommended by health experts to prevent the deadly virus from spreading. Ayaz also stressed that there is nothing in Islamic tradition requiring observant Muslims to shake hands or embrace when they do meet or assemble, saying that embraces should be avoided for the time being and replaced with verbal greetings, such as the traditional “Assalamalaikum” – meaning “peace be with you”. According to the National Command and Operations Center (NCOC) – a forum established to lead the national effort to tackle COVID-19 – the confirmed cases in Pakistan have reached 804,939, some 17,329 deaths have been reported, and 5,075 COVID-19 patients are in critical condition. Nearly two million people have been vaccinated in Pakistan, mainly using China’s Sinopharm vaccine. People waiting to register for COVID-19 vaccines in the Pakistan Institute of Medical Science. Pakistan Proffers Aid to Beleaguered India In response to the rising cases in India, the government of Pakistan banned the entry of travelers from India from arriving at land crossings, which operate in the disputed Kashmir region and elsewhere. At the same time Prime Minister Imran Khan extended an olive branch to the Indian people, writing on Twitter: “Our prayers are for all those suffering from the pandemic in our neighbourhood.” And Pakistan’s Foreign Minister Shah Mehmmod Quershi also offered ventilators, personal protective equipment, and other supplies as a gesture of solidarity with India. As a gesture of solidarity with the people of India in the wake of the current wave of #COVID19, Pakistan has officially offered relief & support to #India, including ventilators, Bi PAP, digital X ray machines, PPEs & other related items. We believe in a policy of #HumanityFirst — Shah Mahmood Qureshi (@SMQureshiPTI) April 24, 2021 India – Virtual Religious and Political Events Could Have Helped Avoid Crisis India has meanwhile seen an outpouring of aid offers from countries ranging from the United States and the United Kingdom to Saudi Arabia and Bhutan – but the question remains whether supplies can arrive in time and whether they can make a sufficient dent, quickly enough, in the ongoing crisis in the country, which now recorded the largest numbers of new cases daily, yet to be seen in any country during the pandemic. Medical supplies from the UK landed in Delhi on Tuesday morning, which included 100 ventilators and 95 oxygen concentrators. Later on Tuesday, Thailand airlifted four cryogenic oxygen tanks to India, Singapore sent 256 oxygen cylinders, Mauritius donated 200 oxygen concentrators. International cooperation at work! Appreciate the shipment of vital medical supplies from 🇬🇧 including 100 ventilators & 95 oxygen concentrators that arrived early this morning. pic.twitter.com/MBZFwSn4cH — Arindam Bagchi (@MEAIndia) April 27, 2021 Resources from European countries are expected to arrive in the coming days, with Germany providing an oxygen production plant, France shipping oxygen concentrators and respirators, and several others pledging support. The EU stands with India. A first shipment of urgently needed oxygen, medicine and equipment will be delivered over the coming days under the EU Civil Protection Mechanism. I want to thank 🇮🇪🇧🇪 🇷🇴 🇱🇺 🇵🇹 🇸🇪 for their solidarity. 🇫🇷 🇩🇪 expected soon. https://t.co/CN0niOY5Lz — Ursula von der Leyen (@vonderleyen) April 27, 2021 In terms of the factors leading up to the crisis, Anant Bhan, Professor in the Department of Community Medicine at Yenepoya University in Mangaluru, said that at least some of the surge in cases could have likely been avoided if stricter measures had been taken earlier on, to control or restrict mass gatherings. “Any large congregations are a major risk factor as we know for COVID-19. Given this, it would have been ideal to conduct any religious or political events only symbolically or use online virtual platforms for these. Failure to do so could have led to events which helped in the spread of the disease,” Anant told Health Policy Watch. Instead, mass gatherings have not only continued unhindered, but they have been marked by a lack of adherence to COVID-19 precautions, especially mask wearing. In addition, the period has seen an increasing number of social gatherings such as marriages and cultural events, which were a factor in the spread. Although India is making a major effort to vaccinate its population, the challenge remains the sheer size of the country and the population – and meanwhile social distancing, mask wearing and other preventive measures remain critical, he said. “The current spread has reinforced the need for a rapid increase in coverage with the vaccines, but supply might be a constraint,” Anant added. While the surge is national, Anant pointed out that some states in India are experiencing a comparatively higher burden of cases, including Maharashtra, Karnataka, Chhattisgarh, Chandigarh, Madhya Pradesh, Delhi, Haryana, Uttar Pradesh. And those, indeed are among the same states that have seen particularly large social and religious gatherings recently. According to the Indian Health Ministry, the number of active cases has risen to 2.9 million, with over 300,000 new cases being reported for the seventh day in a row, and a total of 201,187 deaths. Iran Also Sees Infection Surges Meanwhile, per capita, Iran was seeing almost as large a surge in new cases as India – although it has received far less attention. A medical doctor in Mashad, Dr Ali Zaday, who spoke to Health Policy Watch under a pseudonym due to government restrictions on speaking to foreign media, said that the COVID-19 cases began to spike after the New Year’s festival of Nowruz, which was celebrated for two weeks beginning on 20 March. Last year, festival restrictions were highly restricted, he noted, as Iran became one of the biggest epicenters for the virus during the first wave. This year, however, restrictions were much more was celebrated in a restricted way last year but this year the celebrations were in violation of the COVID-19 SOPs by the public. “Now there are partial lockdowns and daily above four hundred people are dying,” said Dr Zaday. However, a doctor in Tehran, Mustafa Zareef (also speaking under a pseudonym) said that from what he saw, Nowruz celebrations were comparatively modest, and government officials are trying to preserve adherence to COVID-19 restrictions. Mosques were closed in Tehran during “Nowruz,” the Iranian New Year, and public celebrations were cancelled. Even so, the country has still seen a sharp increase in cases since the end of March. He also viewed that comparatively low gatherings were held during the last two years for the Nowruz festival, which is usually celebrated on a large scale. “To a large extent SOPs [COVID standard operating procedures] were also followed during Nowruz,” he said, noting, as one example, that important shrines remain closed – although prayer goers and pilgrims can visit outside. The Iranian Health Ministry reported that over 2.4 million people in the country have now been infected with the virus, with 21,713 new cases recorded on Thursday and 5,287 patients in critical condition – in the country of some 82.9 million people. According to the health ministry statistics more than 700,000 people have been vaccinated with a first dose of vaccines, using the AstraZeneca, Russia’s Sputnik V, and China’s Sinopharm vaccine. Afghanistan Witnesses Slight Rise in Cases Afghanistan has so far largely avoided the negative effects of COVID-19 faced by its neighbouring countries, however, health officials warn that if the current rise in cases is accompanied by a continued disregard of public health measures, the country could suffer the same fate as India. Afghanistan’s acting Minister of Public Health Waheed Majrooh announced at a press conference this week that Afghanistan had already entered the third wave of the pandemic, which is more threatening than the first or second. According to Majrooh, if people don’t follow health recommendations, don’t pay attention to social distancing and don’t wear masks, there is a fear that Afghanistan will experience a catastrophic situation similar to India’s. Kabul-based physician, Dr. Obaid Ullah, told Health Policy Watch that people were reluctant to follow most COVID restrictions until recently. Weddings, religious gatherings and other routine activities have been continuing in full swing. But the deadly surge of COVID-19 cases in India have left more people worried, leading to better compliance with public health measures and greater vaccine acceptance as well. “You would be surprised to know that many were reluctant to get vaccinated and the donated doses of vaccines were reaching expiry date, but that too has begun to change with more and more people going to get the jabs,” said Ullah, whose country is mainly using AstraZeneca vaccines donated by the WHO-supported COVAX initiative. Some 169 new COVID-19 cases were reported on Tuesday across 20 provinces, bringing the cumulative total number of cases to 59,370. Over the past 24 hours, 13 deaths were recorded. Kabul, the capital city, has been the hardest hit. Afghanistan Launches Campaign With Support of Religious Scholars Just this week, Afghanistan launched a nationwide campaign with the support of religious scholars to convince people to adhere more closely to preventive public health measures – warning the public that if they failed to do so, they could suffer the same fate as India. On Tuesday, the country’s Minister of Hajj and Religious Affairs, Mohammad Qasim Halimi, called on religious scholars to educate the people about the threat of coronavirus and encourage them to follow the guidelines of the Ministry of Public Health. Ayaz, Chairman of the CII, told Health Policy Watch that a ‘Fatwa’ declaration – an interpretation on an aspect of Islamic law – had been given by religious scholars on religious practices during the pandemic, which stated that gatherings should be avoided and religious services should be held at home. Image Credits: Sky News, Rahul Basharat Rajput, Press TV. 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