Taking measures

March 17, 2020

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The writer is an American Board-certified rheumatologist at Shalamar Hospital.
The writer is an American Board-certified rheumatologist at Shalamar Hospital.

THE proverb waqt kum hai aur muqabla sakht — time is short, and the race fierce — has never seemed more apt. As SARS CoV2 virus and the consequent COVID-19 rage through the world, many of us are wondering when the ticking time bomb that is Pakistani healthcare will come to a head. The commonly held perceptions that COVID-19 is similar to the common flu or that it is only dangerous to the elderly or immune-compromised are ill-informed. The morbidity and mortality inflicted by the virus is at least five to 20 times worse across all age groups.

While panic helps no one, failing to understand the seriousness of a situation does not either.

At least some of us are considering the possibility that the virus is likely already present in many of our cities, but underreported because of massive under-testing. As an example, most hospitals in Lahore do not have a single testing kit at the moment. In contrast, South Korea, where the first COVID-19 case was reported on Jan 20, has government-paid free drive-through testing by now. You drive up to the testing camp in your car, are met by medical personnel in personal protective equipment (PPE) who test you inside your car within 10 minutes, and you drive away. Results are delivered the next day.

We are an under-resourced country and one does not expect that to change in the next few weeks. The two most important evidence-based measures for fighting the most dangerous pandemic the world has seen in nearly 100 years remain testing and isolation.

Failing to understand the dangers of COVID-19 helps no one.

Flu corners or fever clinics: One powerful measure China employed was re-establishing fever clinics, which they used in 2003 to control the SARS epidemic. If you get a fever or flu-like symptoms, you do not go to a regular hospital, where you are likely to infect others. You go to especially designated clinics, where you are met by healthcare workers in PPE who isolate you, triage, test, and treat you. Pakistan needs to set up fever clinics (or fever tents) in as much of the country as possible where people go to get tested; those and at least one designated fever hospital in every major city where confirmed patients can be transferred, so quarantine efforts are most effective. This can be done on top of utilising already existent dengue isolation wards, mandated by provincial governments.

Social distancing: As Jen Gunter, an American doctor, wrote in the Atlantic, “The concept is simple: Those practising social distancing should stay home as much as possible and look to keep a gap of six feet or more between themselves and others if they do leave the house. The reasoning: fewer interactions with people and the added distance when you must interact means less chance of exposure and hence infection with the virus.”

The Punjab government has begun implementing this. All public gatherings, cultural events, and educational institutions should continue to be shut down for at least four to six weeks while infection numbers manifest themselves.

Educational campaigns: The importance of inexpensive hand soap (which breaks the viral particle) needs to be emphasised much more than the more expensive and possibly ineffective (dependent on alcohol content) hand sanitisers. Avoiding physical touch in social situations, including hand-shaking and embracing, has become of paramount importance. Cough etiquette (teaching people to cough in the crook of their elbow) should be discussed repeatedly on national TV as part of campaign efforts.

Regarding treatment: Wuhan fever clinics have published a triage-and-treat algorithm in the reputable medical journal Lancet. I believe it is useful and the government task force on COVID-19 management is hopefully looking at this when formulating our national response.

Drugs the government needs to be considering for provisioning in­­clude anti-malarials, intravenous Vitamin C, and, for critically ill ICU patients, the powerful immune-suppressants baracitinib, anakinra and actemra.

Most infectious disease specialists and immunologists suspect the virus does most of its damage by activating the immune system and causing a ‘cytokine storm’ — a chain reaction in which the body’s own army of immune cells release a flood of biochemicals that fatally damage the lungs and the heart.

The aforementioned three drugs could be effective in severely sick ICU patients. Perhaps they should be designated ‘controlled substances’ only to be used by senior critical care staff in ICUs across the country. If so, negotiations with drug makers are in order to ensure at least some supply of these for ICU use only.

This is a threat that will require coordination between provinces and the federal government. We are H.G Wells’ martians at the mercy of a microscopic invisible creature; survival depends on indigenous innovation and community.

The writer is an American Board-certified rheumatologist at Shalamar Hospital.

Twitter: @usmantm

Published in Dawn, March 17th, 2020