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Punjab govt is finally preparing to battle COVID-19. Has it reacted too late?

Disorder at hospitals, underequipped doctors, and lack of awareness among the masses, aggravating the coronavirus crisis in the province
by Arooj Khalid & Kunwar Khuldune Shahid

Pakistan’s total number of COVID-19 cases has reached 903 by Tuesday afternoon. Punjab accounts for 265 of them. On Monday, Punjab Chief Minister Usman Buzdar announced ‘partial lockdown’ in the province till April 6 to control the spread of novel coronavirus.

A health emergency had been imposed in the province as the government enforced Section 144 on March 15, banning the opening of all educational institutions and public gatherings. The government has advised citizens to follow preventative measures and exercise self-isolation, while the tally of those infected by COVID-19 precipitously rises.

Chaos at hospitals

Where the Punjab government is now fast-tracking measures to contain COVID-19, it has been criticized for reacting late. Furthermore, the measures that have been implemented have either been deemed inadequate or not properly thought-out.

Investigations by MIT Technology Review reveal that conditions at major hospitals in Lahore not only underline unpreparedness in dealing with the spread of COVID-19, the current arrangements can actually exacerbate the greatest health crisis in a generation.

Dr. Anoosha Shamaun, working in the emergency room of Services Hospital in Lahore, told MIT Technology Review Pakistan that the hospitals are instructed to check suspected patients for symptoms and then send them to the isolation wards accordingly, where their swab cultures are sent to be tested. She said that even with all the arrangements, the resources being provided are not enough to cater to the large amounts of suspected patients coming to the hospital.

“Even before [we were provided with testing kits], people would argue with us to get screened. They didn’t understand that we didn’t have too many resources, and we have a very targeted screening process,” she adds.

As things stand, the only patients being screened for coronavirus at Services Hospital are those who had a travel history or severe symptoms. “Last week, I even had a patient who was faking a travel history, claiming that he had recently arrived from China, just because he wanted to be sure whether he was infected or not,” Dr. Shamaun recalls.

Contrary to the advice of health experts, the isolation wards have been established within the hospitals, instead of allocating special buildings. This has added to the panic among the patients and the hospital staff.

Read more: Pakistani engineer’s team at Microsoft launches COVID-19 tracking dashboard

At Sir Ganga Ram Hospital, which has a six-bed isolation ward for coronavirus patients next to the intensive care unit [ICU] right in the middle of the hospital, a woman was admitted last week. The woman, who had recently travelled internationally showed symptoms of coronavirus, and was brought to the hospital by her brother. She had given her sample to a private laboratory to be tested, but the family was adamant that she be quarantined at Sir Ganga Ram Hospital. None of the family members were there to look after her, and with the hospital staff being underequipped they feared contact with the patient, especially since they had to deal with other patients at the same time.  The situation led to chaos at the hospital with the woman yelling about “being abandoned” by her family and isolated by the doctors. She was discharged the next day after her test came negative.

Doctors underequipped

Just like Services and Sir Ganga Ram, Jinnah Hospital too has a coronavirus ward within the main building, allocated on the fourth floor. Doctors maintain such an arrangement could result in an infected patient spreading the disease throughout the hospital.

Last week, Jinnah Hospital had a patient who tested positive for coronavirus. He was shifted to the ICU and passed away two days later. Many doctors, staff members and other patients in the emergency room had been exposed to this patient without protective gear. None of them were asked to self-quarantine.

Multiple doctors at Jinnah Hospital have expressed concerns over the exposed doctors potentially infecting other staff members and ailing patients, who are the most vulnerable to the fatal ramifications of COVID-19.

The doctors maintain that the number of infections is likely to increase exponentially given the doctors don’t have basic protective equipment. In many hospitals, patients arrive at the emergency room, with no special screening area, carrying the potential of infecting other patients.

Medical experts underscore that for a positive coronavirus contact, one only needs six minutes with an infected patient. It can take up to 30 minutes for a patient to exit the hospital. With the coronavirus wards not isolated, anyone present in the building can get infected.

Young doctors on strike

The Young Doctors Association (YDA) of Punjab launched a strike on March 17 and shut down the Outpatient Departments (OPDs). They also threatened to close the emergencies of teaching hospitals if they were not provided with testing kits and protective equipment.

Punjab Health Minister Prof. Dr. Yasmin Rashid criticized the strike. “The young doctors must feel ashamed for what they are doing at a time when the nation is in a crisis state and the ailing humanity needs their help,” she said.

After a meeting with the Governor of Punjab, Chaudhry Muhammad Sarwar, the doctors called off the strike at public hospitals. The governor assured the doctors that the government would utilize all resources to curb the spread of this pandemic.

The young doctors claim that they had repeatedly asked their hospitals to provide them with personal protective equipment, at a time the emergency rooms have double the number of patients along with the attendants. Many young doctors are critical of the Punjab Health Minister Dr. Yasmin Rashid.

“She doesn’t believe that all the patients should be tested or that the doctors should be wearing protective equipment. Unless we test every patient, we will not really know who is positive or not. It’s possible that if someone gets in contact with a patient who only has mild symptoms, they might get the virus and show severe symptoms,” says a young doctor who participated in the YDA strike.

Read more: Coronavirus in Pakistan: Everything you need to know

The doctors reveal that in the absence of government support many of them have taken it upon themselves to arrange basic hospital gear. In some hospitals, the professors are providing surgical goggles, gowns and masks to young doctors and hospital staff. There is an overall shortage of surgical masks, with the N-95 surgical masks being sold in the black market.

Downplaying the threat

The Punjab government has also come under criticism for some of the statements made undermining the gravity of the current crisis. Dr. Yasmin Rashid has said that ‘Panadol tablets treat coronavirus’, while Governor Sarwar has proposed ‘drinking hot water’ as a cure.

In addition to the government downplaying the coronavirus threat, multiple doctors reveal that the current number of cases being reported in Punjab are far from accurate. This is owing to a combination of insufficient tests being carried out and the government asking the hospitals to “avoid spreading panic”.

“Our hospital does not have the kind of arrangements that the government is claiming. Patients are being underreported. We do not have the diagnostic facilities, so we cannot label if someone is a coronavirus patient or not,” Dr Abeera Wajahat Rabbani from Jinnah Hospital tells MIT Technology Review Pakistan.

Dr Rabbani maintains that the actual numbers is manifold, with “at least thousands in Lahore alone”.

“Instead of hospitals containing the spread of coronavirus, the bigger concern is that it might be spread here. The nurse who passes the IV [intravenous] line to patients, the house-officer drawing sample, for instance, are all being exposed. And the government is doing nothing. I’m a PTI [Pakistan Tehrik-e-Insaf] supporter, but I am very disappointed at the moment,” she adds.

Ominous signs

There is growing fear among doctors that the virus will continue to spread through interaction with infected individuals. The novel coronavirus has an incubation period of 14 days, which means that it can take up to 14 days before an infected patient shows symptoms of the virus. During this time, the patient is a carrier and can spread the virus to others.

Prime Minister Imran Khan addressed the concerns in a televised speech on March 17. He rang an ominous warning claiming that coronavirus “is spreading in other parts of the world where there are better medical facilities… so it will spread further here.” However, the PM urged the nation “not to panic”.

After widespread calls for a lockdown, which had already been announced by the Sindh government, PM Khan addressed the nation again on March 22, maintaining that “lockdown is not an option”. Two days later, Punjab government announced shutdowns across the province, despite maintaining that it is only a ‘partial lockdown’.

The contradictory messages have further enhanced the question-marks over the government’s plans with regards to dealing with the coronavirus spread. Health practitioners warn that the lack of clarity in the action plan in the fight against COVID-19 could aggravate the crisis.

Dr. Rizwan Saigol, the Deputy Medical Superintendent at Mayo Hospital, highlighted the fact that given the incubation period, the actual threat of COVID-19 is significantly more than what is perceived at a given point in time. He maintained that in Pakistan, like most of the world, the people who are asymptomatic carriers of coronavirus are much larger in number than those who show symptoms.

“The majority of the population of Pakistan is young, their immunity is better so they become asymptomatic carriers. These asymptomatic carriers make everyone they interact with vulnerable. Lahore is not fully equipped to deal with such a pandemic. At Mayo Hospital, we only have the capacity to admit one out of every 50 patients,” he says.

Talking about the mortality rate of coronavirus, Dr. Saigol said that a 2% mortality rate has been recorded in places where health services are much more developed. “God forbid, even if 4% of the population of Pakistan is infected with coronavirus, it amounts to approximately 8 million people. And with a 2% mortality rate, this would mean 160,000 deaths.”

Resource allocation

The chief minister has announced a Rs5 billion fund in Punjab to curb the spread of COVID-19. A temporary 1,000-bed field hospital is being set up in Lahore and hospitals are also being dedicated to coronavirus in Muzzafargarh and Rawalpindi, along with 41 high-dependency units in all provincial districts.

In a press conference with Prime Minister Imran Khan on March 20, Chairman of the National Disaster Management Authority (NDMA) Lt Gen Muhammad Afzal claimed Pakistan had acquired 12 million masks in different locations, while millions more were booked with various vendors. He said that the distribution of 12,000 medical suits for health professionals would start the next day whereas millions of N95 masks were also being acquired.

He said that Pakistani hospitals have around 1,700 ventilators and approximately 600 ventilators in the private sector across the country. Even though there is a shortage of ventilators all over the world, Pakistan has booked 800 ventilators with the help of the Chinese government. He also claimed that more testing kits will soon be acquired, which will have the ability to test 90,000 patients.

The National Institute of Health (NIH) claims that Pakistan had acquired polymerase chain reaction [PCR] testing kits from China, which would be distributed to hospitals across the country. In hopes of tackling the lack of coronavirus testing kits, scientists at the National University of Science and Technology (NUST) and Punjab University have made efforts to create low-cost testing kits as well.

However, doctors reiterate that they are not being given enough resources. In a regular government hospital, there are 18 beds in a medical ICU and five beds in surgical ICUs, not all of which have ventilators. At Jinnah Hospital, for instance, there are ten ICUs, all of which are occupied. At Mayo Hospital, doctors are only given one mask every 24 hours. The mask only works for an hour and then has to be discarded.

The hospital staff claim that they haven’t been allocated resources to arrange ventilators for the patients. This means that they have little choice but to refer those patients who can afford the treatment to go to private hospitals. Many others have to be asked to go home.

Those who can afford to get themselves tested from private labs are taking that route. If the private lab tests them positive, they are retested at the hospital, by sending a sample to a government-designated laboratory in Islamabad.

“Now some of the patients who test positive from the private lab, test negative from the government testing kits. Some of these cases are labeled as negative coronavirus patients,” says Dr. Saigol.

Perilous inaction

While the government is looking to enhance its ability to deal with a growing number of patients, many doctors argue that the lockdown should’ve been enforced a lot sooner. “Pakistan’s current trend is worse than any other country in the world. They should’ve done the lockdown sooner,” says Dr. Hassan Butt, a member of the YDA.

Dr. Anoosha Shamaun too fears the government might have left it too late. “If the numbers increase and the severity increases [to a point] where we need ventilators, it might not be possible to control the disease,” she argues.

Health experts also hold the government accountable for they believe is a perilous lack of awareness among the public, which has resulted in the masses not taking preventative measures like self-isolation and social distancing seriously.

“At this point, the spread of the virus can still be stopped, [but] there should be strict measures. If you go out on the streets, you’ll see people all around. They are still continuing their normal routines,” Dr. Shamaun notes.

Doctors underline that not all people from various socio-economic classes watch TV, use mobile phones or have a social media presence. Some reiterate need for better awareness within the hospitals as well.

“There should be recorded announcements on the loudspeaker so that the attendants whose patients are inside the emergency room can know how dangerous it is for them to stay here. They came with one disease and might take another one home. There should be some banners or flexes to provide this information,” maintains Dr. Saigol

“Everyone believes that Allah will take care of them, they don’t make an effort to take precautions themselves. The way the Jummah [Friday prayer] was offered [nationwide], every person who went to the mosque, has made all the people at his house vulnerable to the disease,” he adds.

Two days ago, in Italy, a coronavirus patient was dying every two minutes. “If we compare ourselves to them, which is fearsome in itself, we can see that at first, they didn’t take social distancing seriously either. If we continue to do the same, we are headed toward a catastrophe.”

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