Dr Hamid A. Merchant & Dr Izhar M. Hussain
The CoViD-19 is now a major global health challenge with over 3 million cases and around 210 thousand confirmed deaths worldwide as of the 27th April 2020. Pakistan has recently seen a spike in CoViD-19 cases with around 14,000 confirmed cases and a death toll reaching 300. The actual number of CoViD-19 positive cases in Pakistan is far more than the official confirmed figures; realistic figures can never be obtained in an environment where the diagnostic test can only be offered to the selected few and overall lack of awareness and resources in the country.
The current figures would have surprised many in Pakistan but are they really surprising? Various countries across the world follow a different timeline in the spread of CoViD-19, those who got the disease first seen the surge earlier than others. The CoViD-19 cases in Pakistan still not as high as in Spain, UK, US, or Italy but this doesn’t make Pakistan any special except Pakistan is behind in the timeline. The CoViD-19 curve in Pakistan will eventually hit the peaks seen elsewhere in the world before it gets plateaued and begins to fall. Pakistan had been lucky in terms of getting the pandemic late and had the opportunity to learn from other countries who were not so lucky and had it first, but have we learned the lessons and ready to fight the CoViD19 emergency crises expected to hit the nation very soon?
Pakistan is facing a more challenging environment already and the challenges will only get more intense in the days to come. Not only Pakistan will struggle with the lack of funds, technical facilities and equipment needed to fight the crises but also poor literacy, lack of awareness and culture of non-compliance to advice and regulations is going to make the situation worse.
To tackle the worst medical crises to come soon, Pakistan needs a national emergency taskforce, led directly by the Prime Minister and his senior leadership with a panel of clinicians, public health and policy, pharmacy, law, religion, leadership and strategy experts. The approach can include a rapid response team to help with continuous oversight of national strategy; responding with an action plan on a very regular basis. The article proposes a multipronged approach to help in devising a national emergency response strategy.
Containment
It is vital to contain the disease as a surge in numbers will only mean chaos, where the country will not be able to provide emergency medical care to severely ill CoViD-19 patients, and more people will die in Pakistan than ever anticipated. Lockdown is however very difficult in a country where the majority of people rely on daily wages and the government cannot cope in providing food and necessary living facilities to the whole nation. The surge in temperatures in Pakistan may help to clear the virus from the environment however it cannot stop its transmission from person to person and person to environment, therefore, the lockdown is inevitable and should continue for an extended period to contain the spread of the virus.
Federal Food Reserve
Pakistan will never have enough federal reserves to feed the nation for an extended period, however, it is a country with great human and religious values. Tax aversion is at its peak in Pakistan but charitable contributions are enormously great. It is the time to form a coordinated network of civil society institutions working in liaison with the national task force to help feed the nation. It is important to calculate national food production capacity for essential food such as wheat, rice, sugar, milk and increase production to obtain enough national reserve to feed the nation for the next twelve months. This may require emergency legislation in supporting agriculture, control on export and closely monitoring the national supply chain. Unlike many developed countries, Pakistan is lucky to have the indigenous capability to grow food and a strategically planned food reserve is invaluable to fight these crises.
Medical Equipment and Hospital Resources
This is an area of great concern where the combined provision of healthcare in the public and private sector is not sufficient to cope with large scale medical emergencies. The figures from the World Bank suggest that only half a hospital bed is available per 1000 people in Pakistan. This is five times lower than what we have in the United Kingdom and fourteen times lower than the availability in Germany. These are the figures for a general hospital bed to provide basic medical care; the availability of intensive care units with necessary ventilator support is so limited that we cannot even imagine the scale of chaos awaiting at our doorsteps. It is the time to develop a nationally coordinated strategy to estimate the current provision that can be made by pooling resources from both the public and private sectors and a plan for creating an extended provision in time to fight with the crises to come. Pakistan is not self-reliant in medical technologies when it comes to ventilators and emergency response kits needed by the healthcare professionals to fight the CoViD-19 emergency. Despite, Pakistan is very lucky to have a range of organisations producing electronic and mechanical devices. This includes but not limited to automobiles industry, refrigeration, air-conditioning appliances, electronic and circuits production, textile industry, pharmaceuticals, aircraft precision production, laser and optronics, nuclear energy and high-tech military production. If Dyson, a leading brand of vacuum cleaners in the UK, can come forward to help the nation in producing ventilator beds using their technical and production facilities, why the organisations in Pakistan cannot come forward to help the government in producing medical equipment and kits needed to fight the crises?
Diagnostic Facility
Many countries in the world are struggling to offer the CoViD-19 diagnostic test to the masses of the public due to the niche nature of the test and the costs involved. Pakistan is lucky to have an array of national and multinational pharmaceutical industries operating in Pakistan. A few of them have already developed a diagnostic test for CoViD-19 in their parent countries, could they not support Pakistan to acquire the technology? Can we not locally produce the test kits in Pakistan? Pakistan is lucky to have the talent and human resources capable to fight the emergency crises and various public and private-sector research and higher education institutes have laboratory kits and facilities to help offering the testing service, if necessary technical and financial support is provided. Pakistan is one of the nations, where in times of difficulty, volunteers had never fallen short to provide the human resources needed to fight the crises. A large private network of diagnostic centres in the country can also provide an added resource if needed to extend the provision.
Media and Journalism
The role of media and journalism is a key amid any national emergency. It can not only provide a check and balance and the help to scrutinise national policy but it can also provide emotional and psychological support to the people of Pakistan, particularly in a situation of longer-term lockdown, in boosting the morale of the society by actively playing a constructive role. The media had, unfortunately, played an interesting role worldwide in disseminating premature information, misinterpreted the scientific studies and clinical observations, ignited a political fight and often in instances have made the situation rather worst. Amid a crowd of unethical journalism, some are doing a great job, and their efforts are well appreciated. Exaggeration of drug effects by the politicians and the media, such as anti-malarial drugs, is an example, where we have seen a massive reaction from the public who had illegally stockpiled the available supply from the market. Due to the inappropriate use of these drugs after the media hype, there have also been some reports of severe side-effects leading to deaths. Pakistan, a country, where anything is available without a prescription, is the worst example, where the damage to the public can be humungous. This is the time for all journalism and media centres in the country to come together and reflect on their priorities and play a key role in supporting current crises. A coordinated team effort between different groups may also be an option to diversify the resources in various sectors as per the need of the time.
Like elsewhere in the world, the opportunistic evil forces are also a reality which can be a great threat to Pakistan. Supply of counterfeited or spurious medicines and medical devices had always been a problem in Pakistan; amid CoViD-19 crises, these activities are likely to peak by taking undue public advantage. The supply of fake and unproven treatments and diagnostic tests have been reported across the world. This will only cost more human lives leading to irreparable damage. Coordinated law enforcement in Pakistan is, therefore, a key to fight any unlawful production and distribution of medicines and devices amid CoViD-19 crises.
COVID-19 Vaccine
The vaccine is a great way of immunising the masses and prevents acquiring the infection in the first place. The vaccine developed by the scientist at Oxford University is kicking-off with a clinical trial and is likely to be fast-tracked for approval if succeeded in trials. Despite more than 20 vaccines are being developed across the world, it may take long for vaccines to pass necessary effectiveness and safety trials before they can be offered to the public. Imagine if we would have injected everyone in the world or Pakistan in this context with an unproven vaccine which did not provide enough immunity to prevent the infection, or provided only a short-lived immunity, or had severe side-effects? This would be very counterproductive and any fast-track discovery must carefully consider the safety risk.
Currently, about six out of every hundred people are dying globally who acquired the novel coronavirus. A wrong vaccination could have the potential to kill many more peoples than those currently dying with CoViD-19. It is therefore important to understand that immunisation may not be the first resort in this pandemic and other treatment strategies with strict containment are the key to success.
Therapeutic Intervention
As of today, there is no validated treatment for CoViD-19, however, research is happening at breakneck speed to screen through various potential treatment options, particularly, repurposing existing medicines with an established safe-use history in humans. We must understand that all drugs are chemicals and all chemicals are poisons unless taken in the right form, right amount, and the right time by the right individual. Drugs never work alike in all individuals and there is a huge variability of response and side effects of all medicines in public. This depends on various factors, including the body’s physiology, other medical conditions, overall health status, interaction with another medicine, age, gender, genetics, food, and many more factors. Therefore, there cannot be one treatment for all; a customised approach is always needed for individual patients in managing any disease. Pakistan has a world record number of diabetes and heart diseases, and that can only make them more vulnerable to acquiring a more fatal form of CoViD-19. The data from the world CoViD-19 dashboard suggest that about 20 out of 100 patients who have acquired infection have been recovered successfully from the disease. The figures are promising and it is encouraging that many patients are recovered without any intensive treatment. A fraction of patients will develop a more severe form of the disease where the virus can badly damage lungs to cause pneumonia leading to organ failure and death. Pakistan has a very high proportion of smokers at most age groups and poor lung health can only predispose one in acquiring a severe form of the disease. The critically ill patients, therefore, require breathing support that could progress into intensive care needing a ventilator, a form of artificial respiration when lungs are unable to maintain the oxygen levels. The hospitals will, therefore, need an uninterrupted supply of life-saving drugs and devices.
Pakistan is very lucky to have a big hub of the pharmaceutical industry which already produce medicines locally at large, however, we must not forget that we lack the capabilities to produce raw materials which mainly rely on import. There is an urgent need to develop a national task force to estimate the local pharmaceutical reserves in the country, a list of essential medicines needed to fight the crises, the raw material reserves already available in the country, and the speed of which those can be converted into products with adequate quality assurances in case of emergency. It is also important to ensure that any shortfall in the raw material is carefully estimated and a plan is in place to negotiate a supply from other countries, particularly, China and India. We must not forget that these two countries supply the majority of pharmaceutical raw materials globally; they are already facing difficulties to cope with the demand considering CoViD-19 is a global emergency. The simplest example is paracetamol and ibuprofen tablets – a common baseline treatment for CoViD-19 or any other common cold viruses including flu. Pakistan seems to have ample supply and local production capabilities of both medicines at a very low cost but many would be surprised to know that we do not manufacture the active ingredients present in these tablets in Pakistan. We must member that we cannot continue producing these tablets if active material supply was stopped from overseas. Have we thought about how much reserve do we have nationally and the implications of the shortage of paracetamol and ibuprofen like essential medicines in the country? Therefore, it is wise to develop a federal reserve of essential medicines with a coordinated effort from Pakistan Pharmaceutical Manufacturers Association directly under the control and supervision of national task force to ensure an uninterrupted supply of essential medicines in the emergency crises. The essential medicines list should also include a list of potential medicines that have given some hope in the recent clinical practice across the world, however, caution is necessary to carefully scrutinise the medical literature in ensuring efficacy and safety of the public. The list may include antiviral drugs, antimalarials, interferons, a range of antibiotics to treat upper respiratory bacterial infections and septicaemia, the supply of life-saving steroids, inhalers, nebulisers, medical devices and other supplies used in the emergency. A similar federal medicine reserve has been developed by the US government amid CoViD-19 outbreak where pharmaceutical companies have already started donating millions of dosages to the national stockpile.
The blood plasma from CoViD-19 recovered patients as a source of antibodies for treating critically ill patients with CoViD-19 is an option trialled in China and the USA and results are promising. Nevertheless, the availability of enough ‘healthy’ donors to obtain the therapeutically effective antibody titer in time will be difficult to deal with the current scale national emergency. However, this can still be a useful option to strengthen the national reserve for treating critically-ill CoViD-19 patients. To establish a national pool of coalescent plasma, a coordinated federal strategy is required to track the CoViD-19 positive cases nationally. Offer the diagnostic test freely to the masses and develop a CoViD-19 patients’ database, thanks to NADRA that can make it possible. Tracking CoViD-19 patients then can provide a national reserve of ‘healthy donors’ which can contribute to the Federal CoViD-19 plasma reserve. This would inevitably require a strategy to acquire and produce the test on a large scale as discussed above. Pakistan’s National Institute of Health already has technical capabilities of producing antibodies containing antisera to fight against various poisonous substances, such as snake venoms; and a similar facility is under development in Karachi at the Dow University of Health Sciences.
We must not forget that CoViD-19 is a global health emergency and all developed nations are also struggling to cope with the disease nationally. No one has enough recourses (be medicines or food) to fulfil their national demand, hence, overseas support may not be possible at all amid current crises. Pakistan despite its limited financial and healthcare facilities, is very rich in human intellect, technical capabilities, qualified youth, and ample philanthropists to tackle the forthcoming CoViD-19 emergency crises. Hope this article will provide hope and some help to device a national strategy encompassing a holistic approach to deal with this emergency. We strongly believe that if we play smart, together we can and we will fight Coronavirus!