FROM all indications, the worst is yet to come as the virus’s growth is exponential. Assuming there were 2,500 people infected on April 4, by doubling every six days, there will be 40,000 infected by April 30, of which 6,000 will need hospitalisation and 2,000 will need ventilators. By May 6, these numbers will double to 80,000; 4,000 will need ventilators and 12,000 will need critical care in tertiary care hospitals. Providing this care is not possible. The numbers must be reduced by preventing infections. Hospitals’ burden must be reduced by taking care of those in quarantine and those less sick away from large hospitals.
Although Pakistan lost precious weeks in confusion and lack of united direction, with appropriate actions, we can still make a difference. These actions should be comprehensive and taken simultaneously — a piecemeal approach will not do. An action plan should be prepared collaboratively, in the context of local constraints. Led by the federal government, it should have the sign-off from all political parties, provincial governments and civil society stakeholders. Its implementation should be decentralised, in districts, and managed by district authorities supported by provincial governments.
At the minimum, the national action plan for coronavirus response should have an overall strategy — based on Pakistan’s infrastructure and its challenges — and specific actions. The current practice to bring everything — screening, testing, isolation — into the cities and to tertiary-care hospitals is not wise. Only critical care should come here. All other services should be moved to the districts, where there is a robust management structure in place. Now is the time to use it. Partisan politics should be set aside.
Screening, quarantine, and isolation of the less sick can be done in district and tehsil hospitals. Provincial governments should fill staff vacancies at these hospitals, or give this authority to hospital superintendents. Extra staff should be inducted on an emergency basis — vaccinators, Lady Health Workers (LHWs) and community workers are ideal candidates. Immediate action is needed to:
Appropriate action can still make a difference.
1: Protect front-line workers, with proper gear, manageable work hours, back-up support, and continued enhanced pay. This is a binding constraint. Doctors are getting infected working without PPEs. Soon they will refuse to attend to the sick.
2: Protect hospitals in danger of collapse. Even if offering only critical care, they will be overwhelmed and their load will become unmanageable. Screening of patients, quarantine, and isolation with nursing care should be offered at the district and tehsil hospitals designated only for that purpose.
3: Arrange for extra hands. Paramedical staff such as vaccinators, Lady Health Visitors, LHWs and medical and nursing students should be recruited to care for those in quarantine and those less ill. In Punjab, out of the sanctioned posts for health personnel, almost 50 per cent, or 19, 500, are still vacant.
4: Procure equipment including test kits, PPE and ventilators. Simpler devices, a kind of alternative to ventilators, which deliver oxygen under positive pressure are being developed. PPE and masks can also be locally made. The government should give incentives to manufacturers to help.
5: Test and test. Testing should be increased to cover at least a large enough representative sample of the population. Testing should be taken out of cities, expanded, and delivered onsite in districts at multiple locations using mobile vans, or to laboratories of district/tehsil hospitals. Designated labs should monitor testing to ensure credibility while protecting staff.
6: Communicate, inform and educate. Preventive measures require behaviour change, which is difficult and needs repeated reinforcement. Clear information about the disease and preventive measures needs to be communicated in local languages in a culturally sensitive manner at the community level. Quarantine guidelines issued to prevent the virus outbreak in KP state that homes “should have functioning telephone, running water, bathroom with commode and sink. Besides, [they] should also have separate bedroom for quarantined person for sleeping and eating”. Such directions decrease the government’s credibility.
7: Set up an information system to manage the new systems and collect population data. This information system should be accessible to all stakeholders including civil society representatives.
8: To implement and manage these activities in a timely fashion, there should be a separate national-level manager for each component, who works closely with the provincial administration and reports to the federal technical manager. The effort should be coordinated at the federal level by an accountable and technically capable authority.
The writer is a physician certified by the American Board of Public Health and Preventive Medicine with extensive experience working with departments of public health in the US.
Published in Dawn, April 7th, 2020