Daily Times

Numerous respiratory viruses are known to cause illness ranging from the common cold to Severe Acute Respiratory Syndrome (SARS). Coronavirus (CoV) is a zoonotic pathogen which can be transmitted from animal to human and then human to human through respiratory droplets. During the last two decades, several epidemics have been evidenced across the globe; for instance, in 2002 (SARS), with around 800 deaths, and in 2012 (Middle East Respiratory Syndrome: MERS-CoV), with 860 deaths. Almost eight years after the MERS-CoV outbreak, the current pandemic of novel coronavirus disease-19 (COVID-19) in Wuhan city, Hubei Province, China, emerged as an epidemic and became a global public health concern and pandemic.

On January 30, 2020, the World Health Organization (WHO) declared COVID-19 as a Public Health Emergency of International Concern. Thereafter, in the first week of March, a devastating number of new cases exponentially enhanced globally and the outbreak was considered as a pandemic by the WHO. An average incubation period of COVID-19 is two to 14 days and its human to human transmission is mainly through respiratory droplets, fecal-oral route, and direct contact with infected patient. As of today April 25, 2020, 2,837,463 confirmed cases have been reported across 215 countries. The toll death reached at least 197,703 worldwide. The condition in Pakistan is not very promising though it seems controlled so far. The total confirmed cases so far are around 12,500 and out of these, only 2,755 are recovered and around 251 unfortunately died. If we look at the trajectory, there is still a chance to have more cases in Pakistan. There are various phases of this pandemic, it not only affects the healthcare system but also has a deleterious effect on the country’s economy. Just for a clear understanding of the reader, the phases could be divided into three major phases in simple words as phase 1: identification and planning; phase 2: mitigation and suppression and phase 3: Reversal to normal.

In terms of preventive strategies, we need to understand the trade-off between a ‘mitigation strategy’, which is centered on two-week quarantine of infected households, and a ‘suppression strategy’, which relies on some form of detention of the population (with exceptions essential services workers)

Yet our country is combating with phase one and moving to the second phase bears confusion due to lack of unified national action plan. The current debate at global level is to follow which strategy to keep safe the people as well as the country. In terms of preventive strategies, we need to understand the trade-off between a ‘mitigation strategy’, which is centered on two-week quarantine of infected households, and a ‘suppression strategy’, which relies on some form of detention of the population (with exceptions essential services workers). It needs to be understood that strategies have their own consequences, for instance, the mitigation strategy is costly in terms of lives lost and the suppression strategy is economically and psychologically unsustainable for a longer period. The same debate is going on in our country and the terms we are using for “suppression” are “lockdown” and “curfew” and still depending upon the promising response of the people for self-isolation or quarantine, which seems daydreaming. So far, for instance in Pakistan 124,549 tests have been conducted. However, if we compare the ratio for finding cases and tests; In Pakistan is very high and alarming too i.e., 8.1, while in Spain is 0.19, Italy is 0.14, Iran is 0.25 and India is 0.04

The only solution to defeat this atrocious pandemic is “social distancing”, either self or forced. However, the world economy cannot survive the current social distancing for more than a few weeks. The effects of the COVID-19 pandemic on the global economy are still largely unknown. In fact, it’s true that we cannot predict now because of the uncertainty of how long this lockdown lasts. If this lockdown persists for two weeks or most of three weeks, then the impact on the economy will not be significant. However, it goes more than a month or longer, then it could be undeniably upsetting to the economy. As per UN’s Trade and Development Agency estimates, the slowdown in the global economy caused by the COVID-19 outbreak is likely to cost at least $1 trillion.

No direct measurement has been taken so far for assessing economic burden due to mobilization of health resources on focusing on the management of the patients. The analysis of the conditions of really suffering countries in Europe and the USA demonstrated that delay in taking decisions for complete lockdown depicted distressing results. As a result, it needs sufficient finance and other resources for the suppression of diseases. Having said that we can have an example of China, the trade-off was nowhere as devastating as in Hubei province, but much help from the rest of China, suffered heavily while helping to slow down the spread of the disease across the nation through a forced lockdown. Latest literature showed that adjusting for patient and hospital characteristics, the mean incremental cost of mechanical ventilation in intensive care unit (ICU) was 1,500 to 2000 dollars per day. A hypothetical analysis in Pakistan shows, if God forbid the estimation of patients to load increases exponentially and even only 20% of our total population would be affected and based on our population pyramid at present Pakistan has 11.3 million people over the age of 60 years. Therefore, expected 2.2 million old people may need ICU admission and ventilators out of total affected people so the cost only for intensive care 2.2X1500 =3,300 million dollars per day and 39,600 million dollars per month. However, in our country, the existing data shows that predominantly youngsters are suffering; so, you can imagine the cost for dealing with this group cannot be affordable for a poor country like Pakistan.

Based on current projections, it is strongly suggested the government should pursue a pretty aggressive approach and the government needs to spend at this point in time to prevent the kind of meltdown that could be even more damaging than the one that is likely to take place over the course of the coming months. Recently, in briefing journalists in Geneva, a WHO high official said “it was important not to let grim milestones such as passing the infection rate of 100,000 worldwide, sap resolve to contain the disease, stressing that more than 90 percent of deaths so far have been in just four countries”. It would be the first pandemic in history that could be controlled. Science is evolving quickly, and there is a distinct possibility that new techniques will soon become available that relax at least some logistical constraints mentioned above, such as COVID-19 Rapid Test Cassettes have recently been certified. This new test allows early detection of antibodies specific to coronavirus that does work through blood finger-prick sampling and identifies probably in only 10 minutes the body’s response to coronavirus three to seven days after infection, which would be a big relief of sigh.

The story doesn’t end even after the containment of the pandemic. Another challenge is waiting for us for the third phase. Going back for production in the economy faces additional challenge, which so far not even being considered in any country, including Pakistan. As a matter of fact, it is true, our GDP which is currently around two might go down further and reach a minus scale as estimated by our economic experts. Yet, I would say the stock market or business can be recuperated within six months to one year after controlling this pandemic, however, loss of lives cannot be compensated afterwards by anything. The countries which are still fighting to have more basic requirements for suppression of the COVID-19, like masks, ventilators and hospitals beds, etc. how come would be able to afford to do two tests i.e. serological ELISA for detecting antibodies and another RT-PCR test for that these immune people are no longer carrying the virus. Only those who are positive with a serological test and negative with RT-PCR test should be allowed to return to work. In nutshell, these two tests are mandatory to relaunch the economy at minimum risks of an extra crisis of the epidemic, again which requires a huge amount of money.

In the end, I strongly suggest to follow these a few steps in our country; should behave as a smart nation, respond with corrective measures, not reactive measures, means do not believe in ad hoc measures; at least for coming two more weeks, do not cut lockdown and do not open inter-cities or international transportation; don’t open the markets; use available resources (men, machines, materials and money) rather to make an overwhelmed plan and mobilize resources for that plan; use this crisis as an opportunity for increasing our local capacity for preparation of medical instruments and equipment, and finally instead of appreciating that still we don’t have many cases like other countries and believe we will be saved, import as much as possible test kits and try to assess the size of the problem by doing at least 2,000-5,000 tests per province per day. I repeat the quotation “Perfection is an enemy of the good in a crisis”, so it’s a time for taking decisions instead of thinking and delaying measures for the suppression of the COVID-19, otherwise the loss will not be tackled easily by us in terms of loss of lives and economy too.

The writer is Public Health Specialist & Family Physician, and Head & Assistant Professor Family & Community Medicine Department,College of Medicine, King Faisal University