COVID-19 across the globe – analysis and strategy for Pakistan
COVID-19 across the globe – analysis and strategy for Pakistan
Abdullah Khan
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According to Yuval Noah Harari, in his popular book, “Sapiens – A Brief History of Humankind”, when human beings started domesticating animals after the agricultural revolution that beset some 10,000 years ago, zoonotic diseases appeared to infect the human kind. Zoonotic diseases, also known as Zoonosis are caused by germs, like viruses, bacteria, parasites and fungi that spread between animals and people. Corona family of viruses is also zoonotic in nature and hosted in bats, that transmitted to humans reportedly in China. Individuals with low respiratory infections and symptoms were reported in Wuhan City of China in December, 2019.

According to Yuval Noah Harari, in his popular book, “Sapiens – A Brief History of Humankind”, when human beings started domesticating animals after the agricultural revolution that beset some 10,000 years ago, zoonotic diseases appeared to infect the human kind. Zoonotic diseases, also known as Zoonosis are caused by germs, like viruses, bacteria, parasites and fungi that spread between animals and people. Corona family of viruses is also zoonotic in nature and hosted in bats, that transmitted to humans reportedly in China. Individuals with low respiratory infections and symptoms were reported in Wuhan City of China in December, 2019.

The Chinese Government, after initially investigating through the Chinese Centre for Diseases Control and Prevention (CDC), reported about the disease to WHO on December 31, 2019. The World Health Organization, in February 2020, gave it the name COVID-19, after its causative organism i.e. novel Corona Virus strain.

The Coronavirus first became known to the common masses in 2002-03 when SARC –COV, acronym of Severe Acute Respiratory Syndrome, began infecting people in China, and subsequently involved dozens of countries.

Around 8,000 cases were reported wherein 800 deaths happened. The MERS – COV was another variant of the same family and causative agent of the Middle East Respiratory Syndrome, initially identified in Saudi Arabia in 2012, that later affected other middle eastern countries, also drew the attention of the WHO, the public health specialists and the world leaders to develop healthcare system to prevent the viral and other infectious diseases.

The WHO announced the COVID-19 a Pandemic in March, 2020. COVID-19 has, by the time this article is being written, involved more than 199 countries affecting around 678,073 people, with over 31,746 deaths so far.

According to the reports, about 146, 319 people have recovered. WHO and CDC have issued interim guidelines on how to contains the virus and stop its transmission.

WHO advised the countries to take a whole of government and whole of society approaches and to build comprehensive strategies to contain the virus spread, save lives and minimize impact.

The following four key areas have been reiterated:

  • • Isolate, test and treat every case and trace every contact.
    • Ready your hospitals.
    • Protect and train your health workers.
    • And let us all look out for each other, because we need each other.
    The main theme of the WHO guided strategy is: Prevention, Preparedness, Public Health and People. The WHO has issued the following general recommendations:
    • Avoid close contact with subjects suffering from acute respiratory infections.
    • Wash your hands frequently, especially after contact with infected people or their environment.
    • Avoid unprotected contact with farms or wild animals.
    • People with symptoms of acute airway infection should keep distance, cover coughs or sneezes with disposable tissues or clothes and wash their hands.
    • Strengthen, in particular, in emergency medicine departments, the application of strict hygiene measures for the prevention and control of infections.
    • Individuals that are immunocompromised should avoid public gatherings.

CHINA’S CASE – HOW CHINA RESPONDED TO THE DISEASE:

The World is learning from China the way the disease was controlled in a short span of time. Learning from SARS-COV I (2002-03), the Chinese public health system was ahead of the other countries in terms of preparedness and response to the current COVID-19 outbreak. Moreover; the decisiveness of the Chinese Government has contributed largely to containing the virus in mainland China, contrary to Italy and other developed countries where delayed decisions led to delayed response and devastating effects on health systems and population.

China adopted the following key principles:

  • i. Speed and accuracy in identification and detection played a key role in responding to the disease. Within a week of the identification of the unknown virus, china reported the information to WHO, Simultaneously, measures were adopted to apply tools to screen the infected and the non-infected people in Wuhan.
  • According to reports, initially, no testing kits were available to screen the masses, but within a very limited time, all arrangements were done, equipment’s were made available, hospitals capacity was enhanced by increasing the number of beds, ventilators and building new hospitals.
  • Quarantine and isolation sites were built-in a remarkable shortest possible time. The strategy was to flatten the epidemic curve, through prompt and effective control measures, resulting in slowing the transmission and reducing the burden on the hospitals.
  • ii. Right decisions were made at the right time for the right people. The Chinese policy makers listened to the public health experts and adopted proactive policy. Complete lockdown policy was adopted with measures to ensure supply of food, medicine, healthcare and other needs to the people in the affected areas.
  • iii. Proper information system was installed to manage big data in order to prevent any rebound. Effective surveillance system, up to the lower level, was implemented to track all individuals.
    iv. Strategy to educate the communities about the disease, prevention mechanisms and treatment were timely and systematically adopted.
    Throughout the world, the preventive strategy currently is to control the virus spread and to minimize the cases.
  • Because, according to WHO and the CDC, an epidemic will increase as long as R 0 is greater than 1 (COVID-19 is 2.2.). Therefore, the control measures must focus on reducing the value to less than 1. Globally, the preventive measures are focused on the isolation of patients and effective infection control. Moreover; appropriate care is to be done by the healthcare providers during the diagnosis and the provision of clinical care to an infected patient.

PAKISTAN CASE – PROPOSED STRATEGIC INTERVENTIONS:

The Government of Pakistan got alarmed when it was reported by the International Media that COVID-19 positive cases have been reported in Iran. Iran has got a border of around 959 km with Pakistan in the Province of Balochistan including common sea between the two countries.

At the time, when the transmission of Corona virus was reported in Iran, Pakistani Pilgrims, called Zaireen, were already present in Iran, especially the city of Qom- COVID-19 epicenter in Iran. By the time, the Pakistani Government could take any decisions; some Zaireen had already crossed into Pakistan via Taftan, a bordering town in Chagai district of Balochistan. Nonetheless, it was not yet too late.

Unlike in Italy and other countries of the world, where flights in thousands on daily basis landed from across the world bringing tourists and other travelers in thousands, the source of the virus carrying site was known in Pakistan, viz. From Iran by the Zaireen through Taftan at Pakistan-Iran Gate.

Just closing the border for a specified period of time could stop the virus entry into Pakistan, The Government of Balochistan timely and rightly announced closure of the border in February, 2020. But, since the matter pertains to the Federal Government, the border, due to one or the other reasons, could not be closed.

Quarantine and Isolation Centers at Taftan were established, but still Ziareen could travel to spread in various parts of Pakistan and to cut short, the Coronavirus transmission has started posing threat to the population throughout Pakistan and mainly due to travelers from Iran.

The Government of Pakistan and all the four provinces have issued guidelines from time to time. The major cities in the country have either partially or completely been locked down, and the law enforcement agencies have been directed to prevent mass gatherings.

Quarantine and Isolation centers have been established throughout the country, where implementation of the International Protocols has largely been compromised due to poor governance. All the hospitals have been kept on high alert and equipments are being procured to be provided.

The Government of Balochistan has been proactive in this regard, but lack of preparedness and response due to intrinsic weaknesses of healthcare system in Balochistan and other provinces warrants both short and long term response to manage the calamities of this nature.

If the virus transmission goes beyond the healthcare capacity, it will become a real-time crisis in the country. Therefore, the Government of Pakistan as well as the Provinces should adopt measures to slow down the spread of the disease so as to reduce burdens on the hospitals.

Learning from China and rest of the world, the following steps need to be adopted:

• Complete lockdown of the major cities in accordance with the guidelines of WHO and seeking advice from China may be ensured. Already, this has been done, but proper implementation has to be ensured by any means.
The lockdowns would help in ensuring social distancing and flattening of the epidemiological curve amid Zaireen influx. This would also enhance the reaction time for the government to strengthen health care facilities both for complicated cases, which need critical care and PHC for mild cases.
As WHO also mentions the lockdowns of limited effectiveness in absence of health system strengthening measures. Hence, the time allotted by lockdowns should be used for building health system resilience to address the critical areas of health care system for COVID-19 infection, which will prevail even after the lock downs reach its limits.
• Inter provincial and inter district movement has been stopped by the government, which has to be strictly monitored.
• Social distancing may be ensured by educating people through mass media, social media, mosques and other channels. Writs of the Government may be implemented to avert social and mass gatherings by banning weddings and other social gatherings.
• Religious scholars and religious leadership of all religions and sects may be engaged to stop and minimize gatherings in mosques and other religious places.
• Measures may be adopted to prevent any possible food shortages in the cities due to the inter-provincial and inter-district communication stoppage. If the cities,’ shut-down continues for a longer period, and the communication routes remain suspended, there is high possibility of food shortage, medicine shortage and other civic issues, for which a well-designed strategy may be adopted to ensure uninterrupted supply of food, medicine and other necessary items.
In this regard, the Government of Balochistan has issued necessary guidelines to all the departments with key SoPs for each to adopt measures. All provinces can learn from each other and there should be continuous coordination at the Government and departmental level.
• The poor people, especially the daily waged labor class may be taken care of by the government. Social Security networking can play positive role to cover the poor and marginalized class of the society during the possible employment and earning crisis.
• All the Public Sector hospitals may immediately be equipped by providing necessary equipments. Especially ventilators in large number may be made available in all the tertiary care and secondary care hospitals, and the human resource may be trained on war footing. The private hospitals may also be supported in terms of equipments and human resource by allowing special subsidies and packages.
• General OPDs in the tertiary hospitals have been shut down, which is likely to result into other diseases’ crisis. Therefore, alternative strategies may be adopted by strengthening the primary level healthcare facilities to remain open with due guild-lines to minimize crowds. The Rural Health Centers(RHCs) remains open 24/7, which is possible if the required human resource with medicine and equipment’s are made available.
• The Referral Mechanism with ambulances may be organized on war footing to be ready 24/7, for which both public and private sector may be involved.
• Healthcare workers caring for infected individuals should utilize contact and airborne precautions to include PPE such as N95 or FFP3 masks, eye protection, gowns and gloves to prevent transmission of the virus. The Government is supposed to provide all the items on an urgent basis or the respective hospitals need to make them available for their staff.
Moreover; on individual level, the healthcare providers may also arrange for themselves as it is an emergency situation and waiting for someone to provide them with the items may jeopardize their health and life.
• Epidemiology and surveillance has got a key role in timely detecting the infected individuals and to provide insight for tracing and screening the people around the infected ones.
• Testing kits is scarce in the country, which need to be procured at the federal, provincial and the district level on emergency basis.
The Federal Government and as well as the Provinces have declared Health Emergency, which ensures that PPRA Rules no more apply in procurement relevant to the emergency and, hence, nothing stops timely procurement of machinery, testing kits, medical equipments, medicine and food items, etc. Moreover; pathological labs may also be established in the major cities and as well as at the district level.
• In order to overcome the issue of human resource shortage, all the retired doctors, nurses and paramedical staff may be called on duty by offering them contractual employment. The already available human resource may be trained for meeting any emergency needs, especially managing ventilators.
• Infection Prevention Protocols in line with the WHO Guidelines may be implemented in all hospitals including other government offices and public places. The Local Government Departments through their institutions should arrange for disinfecting the public places on the routine basis till the disease is controlled.
• Funds flow to all the departments and organizations having been engaged should remain uninterrupted.
• Emergency Response System has to be strengthened. The NDMA and PDMAs may be provided with sufficient funding to respond to any situation.
• The Information Ministry and provincial Information Departments shall come up with a scientific strategy to create awareness through all kinds of media.
• The electronic and print media in Pakistan is already playing a very constructive role by creating awareness among the masses to adopt WHO guidelines of hand-washing, social distancing, and respiratory etiquettes, etc. and as well as other key preventive measures. This should further be strengthened.
Each and every individual throughout the country must receive messages to adopt individual preventive protocols, for which mobile companies can play key role. Moreover, the media should also play their role to educate people not to listen to the misconceptions, rumors and false-treatments.
• Public health messages are being circulated for awareness of the people, which may further be enhanced by including nutrition related messages to help boost up the immunity of the people.
• People in the country are undergoing fear and mental stress. The Mental Healthcare system need also be focused upon by engaging the psychiatrists, psychologists, religious scholars and motivational speakers to circulate messages through media and social media in order to help people protect from going into mental stress and possible mental and behavioral illnesses.
• The most important strategy for the populous to undertake is to frequently wash their hands and use portable hand sanitizer and avoid contact with their face and mouth after interacting with a possibly contaminated environment. Supply of Hand Sanitizers and soaps should remain uninterrupted.
• The Federal Government and the provinces have already requested support of Pakistan Army. All the Army hospitals, doctors and other healthcare providers may be kept on high alert. In case, the disease burden reaches the threshold, they may immediately be deployed to support the provinces in combating the disease.
• Strategy for maintaining social order and law and order during the possible health crisis may also be developed.
• The Universities and other educational institutes, especially of Public Health may be engaged for seeking advice on key strategic interventions and for future research and development. Funds may be made available to the Universities and Research Institutions for vaccine development and treatment of the disease.
• A multi-sectoral approach involving all the public sector organizations, in their respective domains with specific assignments, the private sector, the civil-society organizations and as well as the donor agencies including the INGOs may be engaged to respond to any anticipated emergency situation.
• Last, not the least, Policy at the Federal and Provincial level has to be robust, clear-cut and decisive. The Government of Pakistan and the provinces need to develop a comprehensive strategy to manage the current situation, prepare for the expected rise in the crisis in case the disease catches a larger segment of the population, and as well as, to have arrangements in place for the post-disease situation to prevent any possible rebound. Post disease situation will require interventions to rehabilitate the society to its normal to overcome the financial, economic and social crisis that may follow.

CRITICAL ANALYSIS – EMERGING POLICY QUESTIONS:

The MDGs mainly focused on Communicable Diseases such as Malaria, Aids, TB, etc. and, hence, there happened a mentionable improvement in controlling the diseases in many parts of the world. In the SDGs, the focus was diverted to the Non-Communicable Diseases(NCDs), also known as Chronic diseases which are the result of a combination of genetic, physiological, environmental and behavioral factors.

The NCDs include strokes, heart diseases, cancers, diabetes, chronic kidney diseases, osteoarthritis, etc. It seems, the outbreak of the new Coronavirus, the COVID-19 will re-change the global thinking to focus again on communicable diseases, especially the Infectious diseases. The implications of the COVID-19 on public health and other social dimensions are being analyzed by policy experts.

The “Sustainable Development Solutions Network – A Global Initiative for the United Nations” has organized a Global Virtual Conference on March 30, 2020(11:00 – 15:00 UTC) with the Theme:

The Epidemiology and Economics of Coronavirus. The exact wordings of the Virtual Invitation is: “COVID-19 is complicating SDGs implementation efforts around the World and posing a real risk to achieving targets on communicable diseases, education, life expectancy, and decent work. What are the implications of COVID-19 for public health and the SDGs? And how, according to science, should we respond?”. (By the time this article gets published, the event would have happened)

The whole world is passing through a critical phase of the Coronavirus attack, which has revealed, even to the developed countries, that their healthcare systems are still fragile. The soaring death toll across the Globe has uncovered the hidden grey areas in public healthcare systems.

How the world will cope up with the current crisis is still not known, but the domain of Public Policy is becoming wider and global to shape policies across the world. Whether the Coronavirus has posed threat to globalization or will further strengthen it, is another question time will answer. The economists have warned of Corona-economic crisis, even recession is feared to happen if the disease spread is not controlled timely.

Will it end world conflicts or further aggravate the international politics is another dimension the world has to confront in the coming days. Food security and food quality may also become questions of the day with changing dimensions.

What will happen to the demographic changes that have happened due to population control and family planning worldwide? In short, the COVID-19 has caused an uproar in the International Policy circles affecting the whole social, political and economic spectrum’s.

CONCLUSION – WAY AHEAD:

According to experts, there are two possible strategies to control and stop COVID-19. The first strategy, as already being adopted throughout the world and as well as in Pakistan, is to maintain social distancing policy by stopping free movements and gatherings, screening, testing, isolating and treating.

The second strategy is ensuring development of herd immunity, also called population or community immunity, which has got two possible ways: a)vaccinating enough number of the population, probably above 95% of the population against the disease, which, at this stage, has zero possibility as the vaccine has not yet been developed. b)allowing the disease to keep spreading and infecting the people on its natural path, and as enough number get diseased and recover, will naturally develop herd immunity.

But this strategy is not ethically and socially acceptable and is tantamount to the violation of the human right to provide universal healthcare to the whole population irrespective of age, color, economic and social status.

The World is not too far away from developing vaccine for the disease, but it will take time and till then, adopting the above first strategy to ensure social distancing, preventing people gatherings, screening, testing, isolating and treating is the best possible option available with the world right now.

The writer is Provincial Civil Servant and policy analyst based in Quetta.