- Existing structures should be used optinally
By: Dr Nasir Idrees
Corona Virus pandemic is understood to take a longer course than perceived, as more information and time unfolds the curve; and, given the fact, that the vaccine availability is yet distant. Some important up-front suggestions and facts for the government to consider include:
Strategizing the Response: The government should have a strategy in place to combat the pandemic. Rather than learning from mistakes over time and copying or modelling the response of other countries; for we do not have the time for that, and may face catastrophic consequences by the time we end up with this learning curve as every country has its specific environment, economic status and conditions, preparedness and response and no two countries can mimic a similar response. Pakistan’s National Action Plan for COVID19 is a good base to start; although it has a complete set of recommendations, it does not provide a strategic real-time plan – the development of this strategic plan with responsibilities at all levels, the Federal, Provincial, District and Union Council, is essential to place a coordinated response─ specific measures put down for each level inclusive of the private health sector within the geographical boundaries mentioned is essential, for prompt actions and interventions. The roles and responsibilities of the district administration, police, armed forces, health paraphernalia, and the line departments such as food security, NDMA, PDMAs needs to be put down in this strategic framework for a coordinated and responsible effort. This will enable each component of the strategy to know and act accordingly, while the rest do their bit, rather than having a mixed haphazard response with unclear responsibilities.
Lockdown: First we need to comprehend why a lockdown is required, and secondly how to handle this in the Pakistani context, amidst the economic fallouts and true needs of protecting the masses. For this, the federal and provincial governments chart out what they want to achieve and how to phase it out─ phasing out over time is the essential message (the objective of a lockdown is to identify infected, isolate and quarantine, and if possible test, the contacts; treat, retest and move on). In a country like Pakistan where the government has limited resources, with apprehensions of economic consequences for the vulnerable, and limited testing facilities and kits, the best approach is area-wise lockdown and lift approach; if we continue as we are, we may actually see an unending cycle. So we first map out district and union council-wise affected areas all over Pakistan (GIS Mapping); the provincial governments should take the lead, cordon off these areas, immediately test their populations, isolate the infected in out-of-city isolation centres, and quarantine the rest for nine days, retest the quarantined and lift the lockdown in that area, those isolated treated and returned after testing negative. The restriction of movement of the population of the cordoned-off area can then be lifted within the area. Economic activity and daily routine can return for that area (its population will not move out of it until all the district is cleared, and ultimately the province), while other areas are handled the same way– meaning we gradually clear the union councils, districts and provinces and move on.
Additionally, the hospitals (and especially the isolation centres) should have counters like in the banks, as in many countries suffering the pandemic, fully covered with glass, roof to floor, for the medics to encounter the COVID19-suspected (ideally all) patients. The throat samples for testing COVID-19, if required, can be taken from across the counter and ideally by the patients themselves.
Currently we are waiting for any information to come, but we must become proactive searchers of the infected. For the district administration jointly with the armed forces, this should not be difficult, like election monitoring. Ideally the government should spread a message that anyone who feels he needs a test may go to a designated testing site. We are avoiding this currently and asking patients to restrict themselves to the home if they feel they have the virus. Most important, the Federal government should let the provincial governments take the lead, essentially their responsibility after devolution. The solution lies in decentralizing the approach, for optimum results: while the federal government does uniform benchmarking in consensus with the provinces, and looking after the ICT and the federating areas, the provinces should lead implementation within their boundaries.
Special Measures for Medics: Further, special measures need to be taken to account, especially for the vulnerable, in this case the medical fraternity, not only because they are more prone, but also because they can become potential carriers. The safest mode to restrict spread in medics, and to the larger population through them, is through creation of 1-2 quarantine and isolation centres outside the cities, and not in hospitals. Across the world the isolation centres are established either in stadiums, large warehouses, or fields. Sourcing hospitals as isolation centres may prove a great fault, considering the time this pandemic will last and the non-availability of hospitals, or the refusal of hospitals to take up patients suffering from major ailments– it might end up with more deaths from other ailments than from COVID-19 itself, or an upsurge of hundreds of thousands of patients once these hospitals are re-opened for public use; which may actually lead to yet another catastrophe. The armed forces are helping in all countries– they have the capability and training to erect immediate temporary infrastructure of hospitals in times of war; and China presents a recent example. This ability should be used for this need. These temporary isolation centres can be erected in the suburbs and in rural areas. If the existing hospitals are used for longer time, especially in settings like Pakistan where there is minimal protection by re-sterilizing hospitals, these hospitals will turn into potential epicentres; and the loss of doctors to a doctor-constrained country is another grave consequence.
Medical staff, including doctors, nurses, attendants, sanitary workers and auxiliary personnel should be given minimum exposure through rotations of staffs working in these one or two designated isolation centres. They can work in a cycle of 24 hours (wear the PPE and discard after 24 hours) and then be replaced by another team from another hospital, the first team can return after a week or ten days. Minimal exposure reduces chances of being infected. Prolonged working is exhaustive, reduces immunity and has attached fears of infection and spread. Only broadcasting Salam is not enough; you don’t send your soldiers to the border with just Salam and Salutes, you gear them up with arms and protection; doctors are your soldiers in this cause– the Government and the public needs to fully support them with the essential needs.
Additionally, the hospitals (and especially the isolation centres) should have counters like in the banks, as in many countries suffering the pandemic, fully covered with glass, roof to floor, for the medics to encounter the COVID19-suspected (ideally all) patients. The throat samples for testing COVID-19, if required, can be taken from across the counter and ideally by the patients themselves.
Finally, and most importantly, the Government should immediately designate a Research Cell to investigate Pakistan’s Covid-19 epidemiological parameters, start randomized clinical trials and explore manufacturing a vaccine, while we prepare to generate passive immunity providing serums. We have no dearth of statured epidemiologists and researchers– they need to come up to the occasion.