The ongoing pandemic of COVID-19 has already crossed its peak in some countries whereas the worst is yet to come in others. Although China, from where it started, has controlled the transmission, it is too early to say that the virus is not going to come back – despite how vigilant they have been. As of today, almost 3,849,136 people in 212 countries have been affected with nearly 265,929 mortalities. USA, Italy, Spain, France and UK are the worst affected at present, after China. This has raised many questions that need to be answered; why are such countries with high GDP, per capita income, standard of living and overall, relatively so-called perfect health systems the worst affected? It would consume a lot of efforts and thinking along with research to find answers to many of the erupting questions. Not only the public health in these countries, but the total health systems would also undergo a drastic overhaul and health would need to be given primary importance with an increase in health budgets and facilities especially pertaining to unforeseen epidemics like Coronavirus which usually develop when man interferes with the intricate ecosystem developed by nature.

Pakistan is an underdeveloped country which in no way can be compared to the aforementioned states. Our health system is totally fractured, fragmented and insufficient from all parameters, whether we talk of number of beds per population, number of doctors and nurses or other manpower and resources. Our primary, secondary and tertiary healthcare systems are all incapable of dealing with routine medical cases, let alone epidemics/pandemics such as Dengue, SARS and Coronavirus. Overall, the public health system which is the backbone for erecting and implementing policies for such catastrophes, truly speaking has been non-existent.

After the outbreak in China, a uniform and effective strategy should have been devised on war footings to combat the virus from spreading in Pakistan. But sorry to say, disjointed statements were issued by the health authorities with half-hearted measures to block the transmission of the virus from the borders. The first case was reported on 26th February and today the figure has crossed the 24000 mark with nearly 600 deaths. Majority of the patients suffering are in between ages 21-35 years as reported, the aged population has suffered less which seems to be a blessing in disguise as the mortality rate of this virus is very high in aged population. The good news is that amongst the infected, serious cases are less in number as compared to the worldwide figures There may be other epidemiological factors playing their role, like racial and dietary differences and innate and acquired immunity due to frequent exposures to different viruses including Influenza, Dengue, Chickungunya, Hepatitis and other pathogens prevalent in our country but these may just be presumptions. As such, our hospitals are ill-prepared to take the load of routine cases , let alone life-threatening cases of viral pneumonia with resulting ARDS in COVID-19 infection that require advanced pulmonary care and artificial ventilation. Recently, the number of such complicated cases has been on the rise, as a result patients are finding it difficult to get a bed in a hospital with ventilator facilities and recently there was a death of a radiologist in Karachi which is truly a scar on the system. Honesty speaking one or two health facilities of high standard consuming a major chunk of the health budget even if it is from philanthropy doesn’t make any difference. The system catering to the masses has to improve and deliver to make a change because fragmented care only adds to the problems and frustrations. By all means we have to improve the public hospitals and health system to get the desired results for the poor masses.

In such times of dire need the federal and provincial governments should have taken control of all the health facilities. Testing facilities for covid 19 and quarantine and isolation facilities should have been developed on war footings in every city and corner in sufficient number but it took them very long to come up to expectations. With proper SOPs the number of ICU beds should have been increased not only in private hospitals but also in public hospitals. Intensive care units in the latter should have been made functional with provision of all the facilities including the required manpower, gadgets and machinery on an emergency basis, as the number of patients requiring ICU care may increase. We have still not forgotten the turmoil and chaos in the hospitals a few years ago due to an unexpected heat wave causing thousands of cases of heat stroke with innumerable deaths, so much so that the hospitals were full to capacity and these patients could not find a place, resulting in a ruckus that caused many deaths. Not only corona but other patients also suffered due to indiscriminate closure of hospitals and their out patients and honestly speaking deaths in non-corona patients was many times of corona patients and many such lives could have been saved.

A lot has been said and published about how to protect oneself from this curse. The basic universal principal is to practice self-isolation and proper hygiene. The slogan “stay home, stay safe” seems to be very valid. China prevailed out of this situation because of indiscriminate lockdown and isolation; the same is true for other countries like New Zealand and South Africa. If the lock down had been implemented strictly for even a month things would have been different today. The basic principles of tackling with any such pandemic are unified command, standard SOPs for the authorities, medics and hospitals and public separately and then keeping the moral of medics and public high is very important but sadly speaking we failed in all. Carrying out more and more tests was also important but could not be practicable because of multiple reasons. Media has played its role as always, both positive and negative. Both information and misinformation are at their peak. All sorts of remedies, medical, herbal, spiritual and alternative are being shared in abundance not only by laypersons but unfortunately also by medical personnel, confusing the masses. One example is of the chloroquine/hydroxychloroquine drugs. A lot has been written and said about them. Until now there has been no scientific evidence to prove the efficacy of this drug in treating coronavirus but instead the unfortunate consequence of this is that the drug disappeared from the market due to hoarding and its price shot up multifold, and it became unavailable for genuine patients of some autoimmune diseases such as rheumatoid arthritis and SLE which was a real setback for them and their doctors for time being.

The memories of the last major pandemic of (Hong Kong) influenza in 1968 are still fresh. Despite tremendous improvements in medical care, the lessons we learnt from that pandemic including quarantine, isolation and social distancing are the ones that will save us again. This points to the failure of modern medicine to give better solutions in such similar recurrences. Constraints in health budgeting leading to a shortage in the number of medics and hospital beds has led to such a situation that even hospitals in well developed countries have become insufficient to cope up with thousands of patients needing care. For sure, we need to work with public health fellows on war footing to ensure population based interventions including quarantine, isolation and social distancing promptly to flatten the epidemic curve. Then foundations are to be built to prudently respond to challenges of a novel threat like corona. This has to be done with regional and international partners. A pandemic is a long term dynamic issue that requires determination, proactive strategy development and problem solving. By inducing public health measures, expansion in testing through commercial hospitals and public health laboratories can be ensued, reducing number of persons seeking care at hospitals, thereby exposing many. Inpatient critical care needs expansion and drastic improvement with relevant facilities in major hospitals. It is high time authorities should think of increasing the health budget by a substantial amount to improve the care. Developing a vaccine against the virus is what is going to end this misery and despite of all the advancements science has again failed to expedite the desired development once again. Protection of health care workers is mandatory and crucial as they form the first line of defense even at the cost of their own lives. The loss of innumerable valuable lives of doctors and paramedics all over the world has been disastrous and moral breaking for others. The medical profession is the noblest profession, hence it should be the highest paid both in kind and kindness as the cream of the nation enters and undergoes tiresome training and then provides selfless service to humanity without caring about self, family and social life .

In conclusion, reducing confusion and increasing decisiveness along with consensus amongst the authorities is vital. It is high time that merit should prevail in our every decision, since the right person at the right place can really make a difference. Truly speaking, we don’t have shortage of skillful personnel in any or every field. Overall, heartfelt efforts should be made to stop brain drain in this field and also to bring back our highly qualified doctors from abroad but with all the respect and cooperative remuneration they deserve, I am sure many are more than eager to come back and serve their people and country if truly given a chance.

 

Professor Khalid Mahmood Former Dean and Meritorious Professor Medicine, Dow University of Health Sciences, Karachi.