On the face of it, similarity seems stretched. The October 8, 2005 earthquake was an act of sudden and frightening violence leaving some seventy-nine thousand fatalities, many injured and traumatised, and over three and a half million displaced requiring rescue, medical attention, shelter, heating sustenance in winter conditions and eventually rehabilitation. There was no overarching coordinative government mechanism to respond. The task was first handed over to the Cabinet Relief Office and then in short order to the National Crisis Management Cell with its original security mandate. However, quickly a Federal Relief Commission (FRC) under Major General Farooq Ahmed Khan was set up in the Prime Minister’s Secretariat.
It became a hive of activity with many moving parts and daily coordinative meetings of the many departments involved. As in natural disasters everywhere, the largest organised force with the logistic and organisational ability to assist was the military with the Military Operations Directorate as its focal point. There were many moving parts including the Ministry of Health and its military counterpart – all interconnected by 24 action cells, and hotlines also accessible to the public. The Foreign Office’s Emergency Relief Cell started preparing daily lists of casualties and relief needs within 24 hours, which were shared transparently with all the UN agencies and foreign governments; and coordinated 509 foreign relief flights including 117 NATO planes relief air bridge. An estimated two and a half million members of the civic society pitched into the relief effort in a national response.
Pakistan had to play catch up and learn quickly how to do so. The main lesson was that a permanent structure was needed to deal with future natural and man-made disasters. The FRC five years later became the National Disaster Management Authority (NDMA) which in turn set up provincial off shoots. The NDMA is the lead agency at the federal level to deal with the whole spectrum of disaster management activities. It is the executive arm of the National Disaster Management Commission (NDMC) which, under the Chairmanship of the Prime Minister, is the apex policymaking body in the field of disaster management. In the event of a disaster, all stakeholders including government ministries/departments/organisations, armed forces, INGOs, NGOs, and UN agencies work through and form part of the NDMA to conduct one-window operations. Its mandate includes both preparedness and response.
When the coronavirus touched Pakistan, it did so very lightly, whereas in many other countries the numbers subsequently shot up. The response was led at the federal level by the Prime Minister’s Special Assistant for Health – the de-facto Health Minister – an experienced and respected doctor himself, not a technocrat as is usually the case, with a depth of international public health experience. The provincial health setups and the political and operational level had been supportive, with the unfortunate distraction of point-scoring between the centre and one province, the most affected so far, controlled by the opposition.
The government had four main objectives. First; to stop movement from abroad as fast and far as possible and to keep nationals, particularly who had entered from Iran, under observation. Second; to isolate suspected or confirmed cases and track down all those they had come in contact with. Third; to reassure and not to create panic in a potentially increasingly worried public becoming aware of coronavirus’ alarming progress in neighbouring China and Iran and elsewhere daily. Fourth; to urge the public to play its essential preventive role through frequent hand washing, improved personal and living space hygiene and awareness of the symptoms to be alert for and to report if necessary.
Public health experts including the WHO praised Pakistan’s efforts though it also diplomatically observed that its large metropolises and significant mobile workforce population presented major challenges. Policy makers felt that the situation was under control. Then as the danger of the global pandemic became more glaring a National Security Committee meeting chaired by the PM was held on March 13. It resulted in more drastic measures to seal the borders, curtail flights, close educational institutions, prohibit public gatherings and to put the NDMA, now headed by a Lt. General with UN Peacekeeping and relief experience, in charge of the response.
Once this new virus establishes a foothold, the number of those affected tends to rise exponentially to 500 or 600 confirmed cases, then in some cases as in Korea, Iran, Italy and Spain, it goes even further to five to ten thousand cases so far. It should have been foreseen that Pakistan, with its porous borders, inadequate sanitation systems, low expenditure on health, urban population density and lack of public discipline in preventive health practices was not likely to be an exception. Hopefully, once this crisis has ebbed, we have to rethink our priorities and target more of our resources to our health sector just as to education and welfare.
Bringing in the NDMA earlier would have allowed for more effective and coordinated preparations, resource planning and more muscle to get the funds needed from both the government and the IFIs. But what is done is done, what is now important is what to do next.
Information has to be compiled by the NDMA/Ministry of Health, both for policy formulation and implementation and also to be transparently shared with the public to sensitise them to the potential danger from not changing their behaviour patterns. How many tests have been given so far, only then can the probable number of those untested and carrying the virus and infecting others can be calculated. Probably ten times the number of the tests. How much stock of tests is currently available and what is the timeline for the arrival of additional test kits? Given that Pakistan has one bed for 1608 citizens, how many isolation beds and ICUs are there in the coronavirus treatment designated hospitals? How many beds and ICUs do we have in all our government and private hospitals? How many ventilators are available in all of Pakistan and how many anaesthesiologists and trained operators who could service an increase? Is there any assured timeline for new orders? Germany has ordered 10,000, Italy 4,000 and Turkey an unknown but significant number. The EU has banned the export of protective medical equipment without special exemption. The USA will have booked up its own manufacturers. Hopefully orders for ventilators and protective gear will be placed in China. South Korea, which has suggested that other countries should learn from its aggressive campaign, should be asked for assistance in setting up volume virus testing centres. Existing protective gear production within Pakistan should be ramped up. Tent makers should be tasked to make field hospital units to place in parking lots of existing hospitals if there is an overflow. Retired civilian and military medical doctors and nurses should be identified in case they are required. Manufacturers of oxygen and O2 cylinders need to ramp up production.
Many things could have been done and maybe some are in the works. 3M, which is present in Pakistan and used to produce car license plates could have been tasked to set up a line to manufacture its signature N95 masks for hospital workers. Our own engineers that built our only Level 3/4 biotech lab in the NIH should be tasked to start work on negative pressure isolation units. India and most recently the UK, have banned the export of the few anti-viral drugs which in China have been used to some effect to retard coronavirus. We need to compulsorily license these medicines and motivate our pharma companies to produce them. All these things can still be done and would build up our capacity for both future challenges and export capabilities one day.
The public needs to be told that if for instance there is a surge of 5000 cases, will the public and commandeered private hospitals province wise have the capacity to respond? Our most vulnerable population segment of over sixty-five years of age numbers roughly 9.4 million. At any given time how many critically-ill patients can be treated with ventilators? How many will have to be turned away? Developed countries with excellent public health systems and much smaller populations than Pakistan have become alarmed enough to take, for them, draconian measures because if a bulge occurs, they will not have the capacity to treat all those in most need. They are reaching that situation now in Italy and Spain. Perforce doctors will have to triage as they do in battlefield conditions to decide whom to allocate their limited recourses, those with a better chance of surviving and logically the younger over the elder.
As is well known by now, only mass testing to identify and isolate those infected whether or not they display any symptoms; and preventive measures, hygiene and social distancing can the rates of infection be staggered so that there is sufficient capacity to respond.
Boris Johnson laid out the problem and its implications frankly in his address to the nation. As the magnitude of the challenge is much greater here, Prime Minister Imran Khan, in his imminent address to the nation should outline our limited capabilities, and the stark consequences, including more draconian measures the government may have to enforce, if there is no societal awareness and change in behaviour. There is no need to panic if we all play our part but so far, that has not happened.
