First case of COVID19, outside China was announced on 15th January 2020. For an epidemiologist who focuses on outbreaks and pandemics this was the first red flag. That was also the same day I reached out to Dr. Zafar Mirza to request him to assemble a national group of experts in Pakistan to monitor progress of a new coronavirus which has the potential of pandemic spread. He agreed and the Ministry of National Health Services, Regulation and Coordination (MNSHRC) called the first meeting on COVID19 on 22nd January. The Core Committee for coronavirus (later changed to COVID19) was notified which was a group of technical experts, officials of MNSHRC including representation from other allied government officials including Armed Forces.
It grew in its composition and numbers as the gravity of the situation became clearer to other stakeholders. On 21st January globally the total number of reported cases was just 314. Only 5 cases were discovered outside China and even from 309 cases inside China 270 were from Wuhan. However the core committee did not take the situation lightly and very quickly decided to meet on a daily basis. The global reported cases were centered in China so Pakistan started its containment strategy. That means try your best to deny viruses entering into your geographic area. However containment strategies are never fully effective. With our faster methods of travel and longer incubation period means there will be enough silent carriers of the disease.
For that reason we need to strengthen aligned strategies of active surveillance and training on contact tracing before we are hit with a massive number of cases. Group was able to develop an action plan quite early which covered all the important areas including burials before the first case was identified in Pakistan on 26th February. Until 27th March when NCOC was established Pakistan had just around 1400 cases and 11 deaths. Pakistan had increased its testing capacity from zero to 1700 tests per day. There was some system of proper epidemiological data collection at provincial levels and reasonable contact tracing and analysis of that data.
The strength of the core committee was its technical expertise but MNSHC lacked the teeth to enforce its guidelines. I remember the frustration of Dr. Zafar Mirza when every international airline was following Pakistan guidelines of ensuring health forms are distributed in flight before reaching Pakistan except Pakistani airlines including PIA. Active surveillance was never put in operational settings and there were no refresher courses. In the last few weeks of the core committee its decisions were being overruled at some higher level.
Having a quarantine center at Taftan border is just one example. Senior decision makers at different levels were becoming confused and jittery about how to deal with an impeding pandemic. There was certainly a need for an inter-ministerial body with high powers to better coordinate the COVID19 response in Pakistan. NCOC was the answer as understood by many.
The NCOC could rightly give us the numbers of PPE and ventilators it imported and how capacity of beds was increased but unfortunately can’t show with data if it made any dent to the epidemic in Pakistan
Today NCOC has celebrated its 100 days in operation with different events and issuing a report. But the question we should ask is that how really successful has been NCOC as our cases in these one hundred days have been increased from 1400 to 225,000 and deaths from 11 to more than 650? The case positivity rate which was in low single numbers (if we test 100 suspect cases how many will be positive. Lower the value the better it is) has gone up to 25% and is still hovering around 18-20%.
This fact alone shows there is continuous undetected transmission in the community. Higher that value then number of reported cases losses credibility. The early strict but nonpublic health approach of contact tracing by sending police and intelligence agencies officials to round up suspect cases have so badly backfired that every day more patients are refusing to go for a COVID19 laboratory test even though now governments have stopped this approach. Pakistan needs to do 100,000 tests per day as per government own targets but with all the might of NCOC we are still languishing around 20,000/day.
NCOC and Government officials may claim that it was due to the work of NCOC that Pakistan has suffered less damage from COVID as compared to the US and UK. That is the wrong analogy. With five times the small proportion of the most vulnerable age group in Pakistan and a different social system where elders are not put in old people homes we were at the safer footing from the very start. But what about our cases which are less than our own expected numbers from different models? These models have been proven to be nothing better than palmist’s predictions. But starting with extreme numbers they do provide governments a chance to pat on their own backs that they have ‘prevented” so many deaths. I have simple questions for all of them. Please let me know which model has been proven right in three months in advance for any country? There is none!
So why do I think that NCOC has not been able to deliver the results even with such unprecedented multi-stakeholders support? To be fair and put this on record, I was also invited to come to NCOC on a regular basis and I also attended one meeting. Where I felt that NCOC is critical in our COVID19 control strategy but its composition unfortunately was not what was required. In the crowd of federal ministers, Secretaries of different departments, Senior army officers the NCOC lacked the most essential component to fight this war, the technical experts. Recently a famous journalist who has attended a NCOC meeting has written that it was like a Hollywood movie set with data being shown on big screens. But he also wrote that discussion was not about the data which was being shown.
That was exactly my feeling when I regretted attending regular NCOC meetings unless there is a need for an epidemiologist. How could you even think of winning a war if in the operation room there were a lot of PhDs of different disciplines sitting and very few army people? They all may be very distinguished and high ranking scientists but if you need to win a war you need to bring those who know how to fight a war.
But when we thought of making an operation room for our war against SARS-COVID-2 (the virus which causes COVID19) we forgot that lesson. We filled the room with all except virologists, epidemiologists, public health specialists, risk communication experts or anyone remotely trained for outbreaks or pandemics. Fighting an actual war or controlling an epidemic requires a clear line of authority and command. NCOC lacks that as it has two chairs. But again for reasons unknown none has a health background or expertise. The NCOC could rightly give us the numbers of PPE and ventilators it imported and how capacity of beds were increased but unfortunately can’t show with data if it made any dent to the epidemic in Pakistan. NCOC could have played a lifesaving role if it was deployed in facilitation of a technical group.
The way COVID19 is resurfacing in many countries with much higher peaks than earlier one shows that we have to fight this war seriously in the long term to keep our population safe. The natural cycle of diseases should not be misunderstood as equivalent to winning of war. This is no time to pat on our own backs. We need to fill the room with experts who have actual experience of fighting wars with bacteria and viruses. We need to pay attention to their advice and only then NCOC with its strong logistic and influence arm could be of a value (actually tremendous value). It does not matter how qualified and experienced a neurosurgeon may be, if we have a toothache we have to go to a dentist. COVID19 is a public health problem; its solution also lies only in public health.
Dr. Rana Jawad Asghar is an Adjunct Professor of Epidemiology at the University of Nebraska, US, and Chief Executive Officer of Global Health Strategists and Implementers (GHSI), a consulting firm in Islamabad