THE coronavirus infection is well and truly in Pakistan and is growing exponentially as predicted, with over 400 cases diagnosed as of the time of writing — in such situations statistics are outdated by the time they are communicated. The numbers confirmed so far could well be an under-estimate because our capacity to track and test for the infection is limited and already thousands of unscreened people have gone back to their communities.
All the infected will need diagnostic testing. Arrangements made by government are difficult to access and expensive. To get free testing people need to show referrals or passports. Fifteen per cent of the affected need hospitalisation, and 5pc will need ventilators in ICUs. While WHO recommends five hospital beds per 1,000 population, Pakistan’s hospital bed-to-population ratio is less than one per 1,000; in fact, the bed occupancy rate is over 100pc — two patients occupying a bed is a common sight. Government has arranged for separate beds for the coronavirus infected, who will be served by already overworked doctors and nurses.
The infection doubles in number in six days if not controlled. Assuming there are 400 infected today, there will be 102,400 people infected by May 6; 15,360 of these will need hospitalisation and 5,120 will need ventilators. International standards call for 30 ventilators per 100 patients; there are at most 2,000 ventilators nationwide. How far will these arrangements of 300 separate beds take us? One can already see these falling apart and the ensuing chaos.
Facemasks and protective gear, the critical need of health staff who are most at risk of being infected, are in short supply. Allegedly, an infected person admitted to a Lahore hospital was not seen by doctors for 12 hours because they did not have masks. What is Pakistan’s stockpile of masks and protective gear? What are the arrangements for procuring and distributing these?
Facemasks and protective gear, critical to health staff who are most at risk, are in short supply.
All of these factors compound each other. As the system gets overburdened — there are also cases of ‘normal sickness’ that need hospital beds and ventilators — there will be shortages of doctors, nurses, medicines and intravenous fluids. Within days, the caseload, demand on doctors, fatigue, and likely shortages of protective gear will overwhelm the health system. Imagine sick people turning up in hospitals because they cannot breathe. Imagine overworked and unprotected doctors and nurses falling sick and depleting the workforce. One can see the inadequate medical services system disintegrate further.
At the same time, it will become more difficult to track and identify cases. Isolation, even in homes in Pakistan is difficult given that information about the disease is poorly communicated, and there is no monitoring or follow-up system. On March 11, in the waiting room of a large specialty hospital in Lahore, I asked 20 people if they knew about this infection and preventive measures. Not one person did. Most families are crowded in one or two rooms and our cultural practices encourage shaking hands and embracing each other. Social distancing needs culture change.
A security guard, coughing and sniffling, refused to go home. He, understandably, did not want to lose the day’s pay. People who are day labourers will not practise isolation unless they are compensated for their lost wages, otherwise how will their families eat?
Remain calm, trust in God, but also tie the camel. Given that there is no medicine to combat the virus, no vaccine to prevent it, and that it spreads exponentially, the only option is to prevent its spread. For that, there need to be meticulous, detailed plans, implemented strictly according to local challenges and constraints, incorporating lessons learnt from other countries. Plans should be more than standard WHO guidelines and SOPs.
The effort should be led by a special task force headed by a technical expert with experience of managing large health programmes, of Pakistan’s challenges, and knowledge of its institutional strengths and weaknesses. This person should be devoted full time to this task, have credibility and authority stemming from his/her professional experience and personal knowledge and competence, and should be answerable to the prime minister. The government’s plans and strategy should be reviewed and monitored by technical experts representing civil society to avoid a repeat of the Taftan situation where the government’s plan for the quarantine did not work as expected.
The prevention plan should be collective and collaborative between federal, provincial and district governments, with clear roles for and accountability of different government departments, led by the federal government. A budget should be announced with a facilitated release mechanism to minimise procurement delays. The implementation should be detailed in a separate work plan that identifies the responsible person for each activity. The current practice — where no one is accountable, where the National Disaster Management Agency is the lead agency, while a special assistant holds meetings — does not inspire confidence.
The plan should include:
• Cancellation of all public events including religious and commercial congregations.
• Closure of national borders, educational institutions and limitations on international air travel.
• Training of staff on screening practices. Many incoming passengers bypassed screening at airports because the staff was not trained.
• An effective communication strategy in local languages to convey to people knowledge and information about the disease, its dangers, and personal protective actions.
• The number of helpline staff should be increased and trained. Callers to helpline have not always received help, which has implications for the credibility and trust of authorities.
• Clear and factual information to be given to media.
• Economic factors that affect the daily lives of people should be catered for. Sick leave is not common. Many people with mild symptoms, if working on daily wages, are unlikely to stay home and forego earnings needed for survival. The government should make arrangements to compensate for lost wages to ensure compliance.
• Because homes are overcrowded, isolation for suspected infections should be arranged by the government in empty schools, college hostels etc.
The writer is a preventive medicine and public health specialist.
Published in Dawn, March 21st, 2020