Daily Times

The government faces a tradeoff between economic survival and a significant loss of life at this point. The decision is probably the biggest in the last five decades of Pakistan’s history. Here, we debate medical, economic and political facets of the pandemic and try to find solutions to minimize the loss of human life and its economic repercussions.

COVID-19 pandemic has overwhelmed world healthcare systems and economies including that of Pakistan. With more than 52,000 people infected and more than 11,00 people already dead, the peak of disease is yet not in sight. The objective of this article is to understand what we are facing, what we have done till now and what can be the best possible solution to combat with the disease.

But even today, we see people asking a simple question like “do we understand the disease well?” Based on my research, the answer is No! Why No? Let us gather what we have:

The story starts from Wuhan, China, where people start visiting the hospitals with a unique form of pneumonia in December 2019. It rapidly spreads across the community as killer alerting the Chinese government. Soon, it is discovered as a new form of the virus that has emerged, named COVID-19, coined as an abbreviated form of coronavirus disease 2019.

There are many types of coronaviruses, which have previously affected humans. It is assumed that these viruses spread either through interaction between humans and various animals like bats or maybe the outcome of genetic engineering. There is a suspicion that this virus either originated from a wet market in Wuhan or from Wuhan Institute of Virology.

COVID-19 affects 15 per cent of the population causing moderate illness through the milder form of pneumonia and kills around two per cent to eight per cent of the infected. 80 per cent of the population remains mildly affected but these people can silently infect others. The deadliness of bug (a virus that makes organisms ill), is measured by a number of deaths among the infected individuals (case fatality rate-CFR1). Highest case fatality rate in the US is around six per cent; killing around 96,000 people as per the latest figures at the time of writing this article.

The bug is rapidly mutating (a change that occurs in our DNA sequence), having strong and relatively mild strains. In a recent study from the US, 14 different mutations of the bug had been identified and we don’t know their exact biology and severity. This adds further to the complexity and concern to the 100 different companies pursuing effective vaccine development.

For a country like Pakistan, it is almost impossible to sustain a prolonged lockdown

The virus is proved to be highly contagious as it has rapidly spread in more than 200 countries of the world in the last four months. The pandemic nature of a virus in scientific terms is measured by R0 value.

Higher the R0 value more contagious the virus can be. COVID-19 has an R0 value of 2.3, which means that each infected individual would infect 2 individuals at least. One study from China has estimated that the real R0 value can be 5.4, which means that one individual can infect up to 5-6 individuals. Another important point to consider is exponential infection rate which means the number of infected people go up so rapidly that it overwhelms the healthcare system to the point of collapse. Just it has done in Italy, the UK and the US, who have the world’s best healthcare systems. In order to reduce the spread, we have to understand the concept of flattening of the curve.

To flatten the curve, China, South Korea and New Zeeland have successfully taken the measures including social distancing, use of masks, better hygiene, and above all ‘lockdown.’

The idea is to stop the movement of people, localise positive cases and deploy effective quarantine measures. Once the curve is flattened, there would be gradual ease in lockdown. This strategy has worked in these communities because of three reasons: early recognition of the problem and quick action, massive testing capacity, and implementation of compulsory infection control measures. If there had a flaw in any of these measures, the strategy would fail.

Turning the discussion towards Pakistan, March 16, 2020, was the day, when Pakistan had only 26 confirmed cases, a lock-down was initiated. There was a wider consensus that lockdown will be able to keep the curve flattened and things will remain under the healthcare system’s capacity. It remains to be seen if there is any role of pre-existing immunity. It is also noticeable that the number of cases is still rising along with fatalities, which shows the strategy to combat COVID-19 is not yielding the desired results. This failure of our strategy is perhaps due to lack of testing on a massive scale and the compliance fatigue that has set in the public causing them to ignore principles of hygiene and social distancing. It is also perhaps due to lack of resources to implement this strategy on a country with a population of 220 million people. The most important thing to keep in mind at this juncture is that we have not yet reached the peak and the worse is yet to come.

During the last 45 days of this lock-down case fatality rate remained below two per cent, which is quite low if compared to the US and Europe, which is up to eight per cent well within Pakistan’s ability to tackle. The reason for this low CFR is unknown. It has been speculated that in a third world country like Pakistan, probably people have either better immunity against the viruses owing to BCG vaccination, or the viral strain is a weak one. However, there is no scientific evidence to back these assumptions. How long this lockdown should continue? Ideally, until the vaccine is available or the disease somehow dies on its own. Lifting any lockdown when the case numbers are rising is a very risky decision.

Here are a few trillion-dollar questions: when would this disaster end? When would the vaccine be available? For how long you can afford lockdown considering your already bankrupt economy? This adds another layer of complexity to an already fragile economic situation faced by our nation.

The vaccine is likely to be available before the end of the next year. In late February 2020, the World Health Organisation(WHO) said they do not expect a vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), to be available in less than 18 months. Currently, the trials are underway but for the vaccine to be available can take months to years.

For a country like Pakistan, it is almost impossible to sustain a prolonged lockdown. As per recent publications by the World Health Organisation and Yale University, an extended lockdown for developing countries could wreak havoc on their economies and its danger cannot be ignored. There is a high probability of bankruptcy in the coming days despite having debt payment relief from western countries. In a few days’ time, whether people like it or not, the government would take harsh decisions and ease the lockdown to avoid a complete collapse of the economy.

Healthcare system in Pakistan is currently under stress because of many reasons. These include lack of personal protective equipment (PPE), adequate testing services and limited availability of COVID designated Intensive Care Units. The second important component is the poor delivery of existing general healthcare services. The people who are surviving through COVID pandemic have become vulnerable to existing medical conditions. The hospitals have currently limited outpatient, inpatient and elective surgical services, which can explode in coming days and more people may die because of other health problems than the COVID infections. The hospital may need to be divided among various zones to segregate the care of potential and confirmed corona cases apart from the general health services. The hospital would need effective triage, quarantine protocols and testing services along with the provision of PPEs before starting the general health services. Antibody testing here can be the key, which would segregate immune vs. non-immune people.

Is the Government clear about its plans, policies and their effectiveness?

On the whole, there is a lack of clarity among the global leaders on how to tackle this unprecedented situation. However, some world leaders are proving to be a beacon of hope for others namely political leadership of South Korea and that of New Zeeland. They anticipated the threat early, acted effectively and communicated optimally.

In comparison, the Pakistani leadership has given mixed signals and their communication with the nation has left a lot to be desired. This led to a widespread speculative belief that the establishment had to step in and enforce a lockdown while the government was dithering on this important issue. The second failure at the governmental level has been a failure to engage the political opposition and the medical community. This autocratic attitude has negatively affected the national consensus to combat the menace and may spark another wave of political chaos. The ongoing war of the narratives between provincial and the central governments have damaged the nation’s ability to launch a cohesive response to this crisis. Had the military establishment not intervene at this stage, there would have been complete chaos at the level of communication and implementation of policies.

Politics have played a major role in the weak response to this crisis. However, a dilemma would unfold in coming days if mortalities rise and the country’s reserves and the people’s pockets turn empty. Political opportunism compelled the opposition leader Mr Shahbaz Sharif to fly back from London but the central government’s acquiescence to the establishment’s proposal to enforce a lockdown has bought it some time to tackle the disease. Mr Bilawal Bhutto and his team took the lead to enforce lockdown in Sindh and tried to override the central government’s narrative but there was a huge flaw in it, they completely ignored its economic and social repercussions. Amidst this political tussle, the collective wisdom at least partially has prevailed in terms of timely introduction of lockdown.

As discussed above it would be very hard to continue lockdown and would not be economically viable at this stage, hence the government would have to take the risk of opening up the business at least partially to avoid impending bankruptcy and complete economic meltdown. Then how would you avoid the loss of precious life? The answer probably lies in the approach followed by Taiwan. Taiwanese government did not impose a lockdown but their people, adopting a mature approach, followed the social distancing and personal hygiene recommendations to the letter. Our public also has to take it seriously or be ready for the worse. The government needs to ensure the implementation of standardized protocols, which embody the basics of personal hygiene and social distancing. It is high time for the movement to invest seriously in public education and awareness so that people follow the generally accepted recommendations to save themselves from this nasty infection. Also, older than 50 with comorbidities need to be isolated effectively until the vaccine is available.

To conclude, it would be impossible for our government to police the behaviour of its 220 million citizens. Therefore, it is all down to public awareness, participation, compliance and adherence to the recommendations of the social distancing and personal hygiene. Every Pakistani have to religiously treat him or herself as COVID positive individual otherwise things can go out of hand easily! Meanwhile, the government should create opportunities for the public to act on precautionary measures. Masks should be worn by all. It is imperative to follow these guidelines because the lives of our loved ones are at risk. The final death toll would be higher if we find lacking in our response to this mortal danger as we move along with life.

The writer is an FRCS from England, DM (Harvard) fellow of the Royal College of Surgeons of England and former postdoctoral research fellow at Harvard University and currently working as an Assistant Professor of Surgery at Shalamar Medical & Dental College, Lahore