On Friday, March 6, 2020, a family of four — parents and two teenage girls — walked into the clinic area of a large hospital in Lahore. The mother and daughter both had high fever, nausea and dry cough. The medical doctor on call slipped on a mask and, telling them to stay put, walked out of the room to ask the administrative staff about the hospital’s protocol regarding triaging of suspected Covid-19 patients.
The doctor was told there was none.
The doctor was also told there were no testing kits available even if there had been a protocol.
The family’s only option was to go to Services Hospital to get tested for Covid-19. The mother refused to do so because she was exhausted with fever and dehydration.
The medical doctor ended up handing the family facemasks and, except for the mother, sent them home with symptomatic treatment and instructions to rush to the emergency room if they got short of breath. The mother was admitted for observation and rehydration. No testing for Covid-19 would be done on this family.
The same week, eminent lawyer and writer Osama Siddique reported on social media that, upon his return from the Maldives, he found utter chaos at the Lahore airport. The ‘screening team’ consisted of two masked ladies and a guard yelling around, asking people if anyone had returned from Iran or China. In his own words: “I did not see anyone being pulled aside, as no one volunteered this information in my presence. And, if this info was being sought out, it was purely based on the honour code. The masked guy yelled. The two masked ladies simply collected the filled health forms — three at a time — and put them away without glancing at them. The next step was the immigration desks, and I didn’t see anyone pulled away for screening. I also didn’t see anyone with any screening or testing equipment.” Basically, there was no screening protocol in place, no trained triage team or personal protective equipment.
The above, in short, is emblematic of the preparedness of Punjab before March 10 in the face of the swiftest and deadliest pandemic to have emerged on the planet in the last 100 years.
According to some reports, Punjab started testing individuals returning from Iran only in mid-March. And even as the number of detected cases spiked to over 180 in Sindh, the number of confirmed cases in Punjab remained suspiciously low.
While the Sindh government more swiftly sprang into action, response at the federal level has continuously appeared to underplay the situation’s gravity. Addressing the nation on March 18, Prime Minister Imran Khan gave his signature advice to Pakistanis. “Ghabrana nahin hai [You do not have to fear],” he told his countrymen.
But the whole world is fearing the worst — and with good reason.
Since December 2019 the global health community has been watching the Covid-19 outbreak unfold with disbelief. In January, the World Health Organization (WHO) declared the novel coronavirus as a global public health emergency. On March 11, WHO did something it has not done in more than a decade: it declared Covid-19 a global pandemic.
Around the world, the medical community remains filled with uncertainty and quite a bit of dread.
Some of the dread is because there is no vaccine yet, and a lack of information, coupled with an abundance of fast spreading misinformation, has contributed to this feeling of panic. As scientists around the globe work towards a solution, they are urging people to practice social distancing in an effort to contain the virus.
You might have heard the term “flattening the curve” online or in media discussions. What that means is that pandemics are often difficult to contain and may end up infecting huge chunks of a country’s total population. So while the AUC (Area Under the Curve) of the graph above might stay the same — the total number of infections might remain constant — measures like social distancing and aggressive testing could potentially ‘flatten the curve’, preventing the local healthcare system from getting overwhelmed by, say, thousand of cases in one week.
The issues with that nightmare scenario are two-fold:
Because of the limited number of beds, healthcare professionals and ventilators, hospitals cannot handle too many sick Covid-19 cases at once. This leads to an increased number of deaths of both Covid-19 patients and other patients who seek care because of trauma or other problems.
Because the system gets overwhelmed and breaks down, the risk of infections spreading in healthcare workers and other patients goes up as well, creating a vicious cycle.
R0, CASE DOUBLING, AND THE ANATOMY OF AN EPIDEMIC
R0 (pronounced R-naught) is an epidemiologic term that refers to the average number of people that one sick person goes on to infect. It is used to predict how far an epidemic might spread in a population with no natural immunity to the virus.
The currently believed R0 for the SAR-CoV-2 virus is about three.
At the time of this writing (March 21, afternoon), the total number of official Covid-19 cases in Pakistan is 510. Which means people who will be or might already have been infected by these cases is around 1,530.
Every single person of these 1,530 could be a disease cluster.
Keep in mind that this is likely a vastly under-diagnosed number because of very limited testing capability.
Now, as Dr Liz Specht, an engineer and Director of Science & Technology at The Good Food Institute recently observed, cases usually double “every 6 days (… a typical doubling time across several epidemiological studies).”
This means that without aggressive containment measures, even these original 510 cases will lead to:
March 27 — 1,020 cases
April 2 — 2,040 cases
April 8 — 4,080 cases
and so on.
By April 14th, Pakistan may have 8,160 confirmed cases
By May 2nd, 65,280 cases
By June 1st, more than two million confirmed cases of Covid-19
This is the most conservative, best-case scenario because we haven’t factored in the fact that at any given time, the actual cases in a population are around 8-10 times more than the lab-confirmed cases.
Which could mean up to 81,160 actual infected cases by mid-April and over 20 million (2 crore) by June.
Do we honestly believe we have enough hospital beds, facemasks, mechanical ventilators, and healthcare workers prepared for such a massive healthcare burden?
Similar actual case numbers (80,000 infected) for mid-April were calculated by analysts Osama Rizvi and Ahsan Zahid who used a mathematical model proposed by engineer and data analyst Tomas Pueyo.
Rizvi and Zahid also predicted a massive shortage of beds in all the provinces of Pakistan as the number of infected patients rises, which can be seen in the graph above: As number of days pass, the red curve (number of true cases) hits 80,000 by mid-April, juxtaposed to the total number (132,227) of available hospital beds in Pakistan, (many of which, independent of Covid-19 cases, are already in use at any given time).
And as we all know, by May/June, dengue will be back in Pakistan with a vengeance.
Dr Specht has predicted that, by July 2020, between two to six billion people around the world will be afflicted with Covid-19. We are looking at massive healthcare failures all around the world and especially in Pakistan before the end of summer, if mass testing and severe containment measures, including social distancing, are not undertaken now.
Some of the dread is because we do not understand the enemy.
How did the likely zoonotic virus cross over from animal to human?
On December 30, 2019, three lung washing samples were collected from a patient in Wuhan Jinyintan Hospital who had pneumonia of unknown cause. The samples tested positive for a new Coronavirus strain, whose genetic analysis was most closely related to the bat SARS-like Coronavirus strain. The virus was named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the illness it causes was named Coronavirus Disease (Covid-19).
How is it transmitted?
The Centers for Disease Control and Prevention (CDC) in America believes respiratory droplets are the likeliest mode of transmission. When an infected person coughs or sneezes, droplets splatter on surfaces or another person’s body. This means you would need to be in close contact (within six feet) of a person or touch those droplets to get infected. However, a recent study reports small droplets could remain airborne and infective for up to three hours. That means the droplets could be inhaled in; which means the virus can be transmitted as an airborne infection.
Why is the incubation period a problem?
Unlike SARS or H1N1 Influenza (common flu), with Covid-19 you could have zero symptoms for up to five days and still be shedding the virus and infecting others. This means you might believe you’re healthy since you have no fever, dry cough or shortness of breath. In the absence of aggressive social distancing you might decide to visit the gym or your local mall and scatter a hundred thousand viral particles or droplets in the area, never knowing you were the vector of disease.
Why does Pakistan have such a low number of cases?
One finds this curious. We’re right next to China and Iran, after all, two of the most heavily infected countries on the planet. But it is important to remember that it is the number of detected cases that is comparatively low (and now quickly rising). From experience, this writer knows that very few places in Lahore, for example, are currently testing for the virus — which suggests the reported official numbers may be lower than actual cases of Covid-19, an ominous conclusion.
One might argue that India and most of Africa have relatively few cases, too. Could this suggest there is something to the ‘latitude theory’, after all? That hot climate discourages viral spread? We do not know yet, especially when we take into account the significant number of cases reported in Australia, Singapore and Brazil — all currently warm weather areas.
At the time of this writing, it has been confirmed that the virus has spread to 26 African countries. Many of those countries’ totals are still in single figures.
What, if anything, could prevent the progression of a mild case (sniffles, cough, muscle aches, a low-grade fever or walking pneumonia) to a severe case (life-threatening illness with difficulty breathing and need for oxygen or mechanical respiratory support with a ventilator)?
While there are risk factors (underlying pre-existent medical conditions, age and certain biochemical markers in the body) the fact remains that we do not know which patients will develop the worst disease. At the moment, the only known is that Covid-19 Case Fatality Rate is at least five times worse than regular flu at any age group, except children, who seem to get mild symptoms mostly. Even in that age group (between 10-19 years of age), some data from China suggests increased risk of morbidity and mortality compared to the flu.
Some of the fear is because we have a collective memory as well as written chronicles of a similar enemy.
The so-called “Spanish Flu” of 1918 was a devastating pandemic, which spread like wildfire around the world infecting around 500 million people (27 percent of the world’s population at the time) and killing about 17 million (as estimated in a study in 2018) — a mortality rate of around three percent.
At the time of this writing, the current mortality of Covid-19 according to Worldometers is around 4 percent with the total number of infected cases having exceeded 200,000. This is comparable to the 3.8 percent Crude Fatality Rate (CFR) in infected patients in China, as reported by the WHO.
The similarity of numbers between the plagues of 1918 and 2020 is chilling. By the time the Covid-19 pandemic peters out, should we expect comparable totals this time around too? This writer fears that would be optimistic. The world’s population has more than quadrupled since 1918 and, as a species, we are much better connected now than we were back then — which means easier transmission with higher numbers.
At the time of this writing, the total number of cases in Italy reported by Worldometer are 31,506 with 2,503 deaths, the mortality rate is around 7.9 percent — the worst in the world at the moment (Iran’s current reported mortality is around 6.1 percent). Washington State, the area worst-hit in the United States till last week, has reported a total of 1014 cases with 55 deaths; mortality around 5.2 percent. CDC is expecting at least 160 million infections in the US alone. That is roughly half of all Americans.
This writer fears, when all is said and done, if every single government around the world doesn’t do its part diligently, we might be looking at much larger morbidity and mortality numbers than the Great Influenza Pandemic of 1918.
We humans are trying to walk the line in a manifestly dystopian landscape.
From Mary Shelley to Edgar Allan Poe, from Begum Rokeya Hossain to Margaret Atwood, from Albert Camus to Stephen King, writers of fiction have carried out thought experiments in dystopian and alternate world writing. These extrapolate from historical and contemporary sources to describe the upheaval of the status quo and the end of the world, as we know it. Writers of science fiction have been especially good at it.
It is unfortunate, though, that writers’ warnings about the Climate Apocalypse, the Anthropocene, the scale of capitalistic disregard of the environment and subsequent human-inflicted damage on the planet have gone unheeded. Humanity continues to invade and gouge out spaces once inhabited by animals and plants. As Alanna Shaikh, a global health expert and TED Fellow, said in a talk on March 11, 2020, “This is not the last major outbreak we’re ever going to see. There’s going to be more outbreaks, and there’s going to be more epidemics. That’s not a maybe. That’s a given.” If we accept that — and this writer thinks we absolutely should — we need also accept that all those fictive dystopias once thought many years away have finally caught up with our present.
Reworking the words of the science fiction writer William Gibson: The end of the world is here. It’s just not evenly distributed.
Covid-19 may be here to stay.
It may roar across the globe and boomerang back to Asia; or it may go quiescent, as many seasonal strains of flu do, and return next winter as an endemic virus that learns to cohabitate with us.
Either way, Pakistan needs to be prepared for its return; to learn to coordinate its emergency response in the face of future threats of epidemics, to marshal its means and resources to provide the most cost-effective healthcare and environmental solutions. Our demographics are in our favour; why not start tapping into our youth’s limitless enthusiasm and obvious intelligence? Where are our especially designated science teams who could go out to rural areas and teach basic science concepts through narratives in regional languages? We have thousands of aspiring data scientists looking for experience, medical students in need of research projects and college graduates looking for decent jobs. Why not utilise them to create networks of telemedicine, where basic health questions could be answered using telephones or, at most, Skype or Facebook Messenger? Why not reward young entrepreneurs who create new apps, wherein users can log Covid-19 symptoms and be immediately directed to helplines with up-to-date triage information about the closest fever camps or clinics with testing-and-treatment capabilities?
Of course, before these measures can be introduced we need to work towards clinics with such capabilities. While in these uncertain times one is tempted to think about a brighter future, the need of the hour is swift action. As the federal government mulls over doing even the bare minimum like encouraging social distancing, the virus is spreading and the economy is tanking.
We must learn from the quick spread in countries like neighbouring Iran, and ready our defence before time runs out. Otherwise, the virus will torpedo our lives in more ways than are immediately obvious. As the world is fast learning, it's not a question of if, but when.
Usman T. Malik is a science fiction writer and American Board-certified rheumatologist. He works at Shalamar Hospital and Shalamar Medical & Dental College
Header illustration by Samiah Bilal
Published in Dawn, EOS, March 22nd, 2020
Two of the most accessible resources this writer has found are the Worldometer website, which provides minute-by-minute accurate data about the global Covid-19 disease burden; and the website www.informationisbeautiful.com, which has lovely visual data and aids to better comprehend this disease with.
Recent data reviewed by this author from peer-reviewed papers accessed through search engine PUBMED suggests:
TRANSMISSION AND EPIDEMIOLOGY
The SARS-CoV-2 Virus is a single stranded RNA virus, the seventh and newest member of the coronavirus family.
The virus can be transmitted human-to-human as respiratory droplets from coughing or sneezing.
Asymptomatic carriers can shed the virus during the incubation period — generally within 3 to 5 days, but may be up to two weeks.
Affected patients’ median age is around 59 years, but anyone from an infant to up to 90 years of age can be affected.
Mortality rate is highest in people above 80 years of age. Mortality rate is almost zero in children less than nine years of age.
The leading cause of death remains respiratory failure; followed closely by cardiac problems.
Most common symptoms in mild disease include fever, dry cough, muscle aches and sore throat. Runny nose and stomach problems are much less likely in Covid-19 compared to the Flu.
In moderate disease, cough and shortness of breath are present without signs of severe pneumonia.
Severe disease can range from severe difficulty breathing, chest wheezing and high fever to severe respiratory distress with need for Oxygen mask or invasive mechanical ventilation (on life-saving machines).
The respiratory problem can be compounded by damage to heart tissue (fulminant myocarditis), life-threatening cardiac arrhythmias, and severe damage to other organs such as the kidney or the gut, leading eventually to death.
The leading hypothesis about the reason some patients get severe lung and heart injury postulates that there is an unchecked immune reaction leading to severe systemic inflammation called a ‘cytokine storm’.
What that means is that in trying to get rid of the virus the body mounts an extremely powerful defence, which spirals out of control, leading to catastrophic self-damage.
This is supported by reports of significantly high IL-6 and CRP levels — two proteins the body releases in states of stress or inflammation — in patients with deadly outcomes.
The excessive immune response might be because the human body has never seen this strain of coronavirus before and has no existing templates to use when responding to its invasion.
There are no medications that have clear evidence-proved benefit in treatment of Covid-19.
Broadly speaking, medications currently under investigation include drugs with activity against the virus and drugs that dampen the body’s life-threatening immune response.
Groups from different countries such as Italy, China, Singapore, South Korea and the US have published various guidelines and algorithms for treatment.
Prevention and containment continue to be the best treatment options for Covid-19. — UTM
Steps beyond already implemented measures that could be of potential use in Pakistan:
Fever clinics/ camps: Set up designated fever camps outside most hospitals and urgent cares in every city. Patients seeking help would be directed by guards to these camps, where they would be triaged, tested, treated, educated and quarantined, if need be. (Environmental sociologist Nuzhat S. Siddiqui recently suggested using Orange Line Metro Stations in Lahore as isolation wards — the kind of innovative thinking we need to grapple with this crisis).
Fever hospitals: Every major city should have at least one designated fever hospital, where confirmed cases are sent for care and quarantine. These could be existing facilities or makeshift hospitals adequately supplied with personal protective equipment for the healthcare workers.
Fever screening should be done at the entrance of every major public venue, including malls, public squares and shops in Pakistan.
ICU capabilities of Pakistani hospitals and the number of available mechanical ventilators should be rapidly expanded.
A designated Covid War Room or Central Command at the NIH for infected cluster tracking and data analysis.
Partnership between private labs and the government to subsidise testing of patients. For example, the current cost of getting tested for Covid-19 at private labs in Punjab is 7,900 rupees. The government should consider negotiating with these labs to bring costs down for the average citizen while inexpensive testing is worked on.
Partnership with academic and research centres to accelerate production of inexpensive testing kits.
Expanding telemedicine services to allow quick symptom screen and triage on phone and laptops. (As I wrote these words, Tania Aidrus, who’s working with the WHO, put out a call on her social media for telemedicine companies and start-ups to contact her for similar purposes).
Increase production of antimalarial and antiviral agents and ban all export.
Awareness teams sent to all ‘mohallah GPs’, hakeems and homeopaths for education and direction, to send suspected patients to fever camps. — UTM
At the time of this writing, various medical groups in China, Italy, South Korea, Singapore and the US have published guidelines and recommendations for the treatment of Covid-19 disease. It is important to understand most of these treatment guides are based on limited or anecdotal data.
GENERAL PRINCIPLES OF TREATMENT
Supportive management with cautious use of fluid; oxygen therapy; judicious use of antibiotics to prevent superimposed bacterial pneumonia and protective early intubation and mechanical ventilation.
Antiviral agents including the HIV drugs Lopinavir/ritonavir (either alone or in combination with the Hepatitis C drug Interferon B or Interferon Alpha); the experimental antivirals Remdisivir (in trials by Gilead Sciences) and Favipiravir (in trial in China); the antimalarials chloroquine/ hydroxychloroquine; and the broad-spectrum antiviral Ribavirin.
Immunosuppressant drugs: Actemra (IL-6 inhibitor) is being fast-tracked for approval in China for use. Baracitinib (JAK inhibitor) and Anakinra (IL-1 inhibitor) are also under investigation.
The use of systemic corticosteroids is not recommended by the WHO or by medical groups in Italy and Singapore for ARDS or viral pneumonia because of previously reported possible harm in SARS and MERS patients.
Convalescent plasma (serum extracted from recovered Covid-19 patients with possible antibodies against the virus) seems to be a promising treatment and is currently in trials. This may be a feasible local option for Pakistani drug companies and scientists to consider.
EXAMPLES OF SPECIFIC TREATMENT GUIDELINES
China published an expert consensus that recommended chloroquine phosphate tablets, 500mg twice per day for 10 days for patients diagnosed as mild, moderate and severe cases of novel coronavirus pneumonia and without contraindications to chloroquine.
South Korean guidelines suggest lopinavir /ritonavir or chloroquine orally per day. As chloroquine is not available in Korea, hydroxychloroquine 400mg orally per day is being considered.
At least one paper suggests that blocking Angiotensin II using ARBs (Losartan etc.) might reduce aggressiveness and mortality in ARDS/Acute Lung Injury resulting from Covid-19 disease. However, no society guidelines currently recommend use.
The National University of Singapore has published the COVID-19 Science Reports: Therapeutics summarising the latest findings in therapeutic options and the clinical trials currently in progress (March, 2020)
A Chinese medical group on the frontlines against this disease has published a Rapid Advice Guideline for the Diagnosis and Treatment of 2019 Novel Coronavirus Infected Pneumonia (Feb, 2020)
The World Health Organization (WHO) has published A Coordinated Global Research Roadmap, a broad consensus on the need for urgent research and focus on actions that could save lives now (March, 2020)
The WHO has published a Report of the WHO-China Joint Mission on COVID-19 that outlines the viral transmission in China and the measures that were successful in containing it (Feb, 2020)
A clinical trial looking at efficacy of the HIV combination antivirals Lopinavir/ritonavir has failed to show benefit of using these medications in COVID-19.
At the time of this writing, there has been panicked buying of chloroquine and hydroxychloroquine, which have demonstrated some efficacy in moderate to severe COVID-19 illness. The author wishes to caution the public not to use these medicines for preventative purposes, since there is no evidence to that effect, and to point out the significant potential toxicity (heart, skin, nerves, muscles) of using these drugs in absence of symptoms.
Please also note, these are medications used in rheumatologic medications and stockpiling or hoarding could lead to severe consequences for rheumatology patients who actually do these medicines to survive.
Pakistan, more than other countries, needs a vision reboot. From the shrivelling of the Indus River to water-deprivation deaths of children in Sindh and Balochistan, we have paid little thought to the effects of climate change and human politico-economic activity on our and the planet’s survival. Both are intimately connected with local and global public health concerns. Neither has been studied adequately enough to induce policy change at meaningful levels.
Now that we have dengue in the summer and Covid-19 in the winter, perhaps it is time to rethink our priorities, to induce a paradigm shift in the way we plan our future. At the time of this writing, there is not a single Pandemic Watchdog in Pakistan, let alone a Centre for Future Studies or an academic institution that specialises in teaching science fiction literature. In a world where the US government partners with science fiction writers and astronauts, putting them on the same council (look up Jerry Pournelle and the Reagan Administration’s space initiatives); where large corporations and organisations such as Nike, Ford, Visa and NATO enlist futurists to imagine fresh designs and use of their products (see Ari Popper and the writer panel of SciFutures); where science fiction writers deliberately choose to write stories that could influence chief executives of major tech-development companies (see Ken Liu and his work with SciFutures), it is a pity that Pakistan, a country with limited resources and low literacy, is not encouraging Futurism as a valid career and the literature of thought experiments — Science Fiction — to imagine alternates presents and futures.
In 2012, the Arizona State University established the Center for Science and the Imagination. The Center’s stated goal is to “[bring] writers, artists and other creative thinkers into collaboration with scientists, engineers and technologists to reignite humanity’s grand ambitions for innovation and discovery.” The centre is meant to serve “as a network hub for audacious moonshot ideas and a cultural engine for thoughtful optimism”.
Perhaps it is time for Pakistanis institutions too to put their heads together and create a Centre for Desi Imagineering and Innovation.