Get ready for Hospitals' saturation after Eid in Pakistan
We have been debating about Lockdown for the last 5 months now. As a developing country with recent economic recession & 2 out of 3 Pakistanis living as poor, having extended lockdown is a luxury we couldn't afford as a nation. While NGOs & Government tried their best to reach everyone, question is that did they? Biggest issue is that this disease has also precipitated a cycle of joblessness, bankruptcy, liquidation leading to demise of small businesses as well. Under extreme public pressure, Pakistan opened up after observing almost 2 months of Lockdown. However, as soon as the Lockdown opened, people came out in large crowds in all Bazaars. SOPs could not be observed. It is not because people were not made aware of the risk of exposure & not observing SOPs. It is due to public's individual decision to not comply due to an inherent disbelief in the validity of this disease. People do not trust the mainstream media or the politicians. They just do not care how many times they get SMS or a phone voice alert about COVID19. They want to do what they have been trying to do. Survive. Confront the recession. Try to reboot business. Try to earn a living.
Why Pakistan cannot have extended Lockdowns?
In a democratic environment, imposing draconian lockdowns for long is impossible especially when the masses are starving & have inadequate aid due to fiscal constraints of the government resources. In such a scenario, Imran Khan's government focused on a relaxed lockdown to allow blue collar workers to go back to their jobs. This was to prevent hunger crisis that could lead to mass civil riots. Now, as the bazaars are opened in anticipation of Eid & under pressure of traders, people are flooding the stores. Some wear masks. Others don't.
What to expect;
This could lead to 2 possibilities;
1) Crowds of this extent could precipitate herd immunity fast. At present per the test positivity rate of 11%, 24 million Pakistanis are already suffering from COVID19. As exposure increases through end of Lockdown, the number of confirmed cases will escalate possibly crossing 100,000 by the next week. By the time it hits to 150,000, more than 1/2 of Pakistan would be affected by Coronavirus. Out of which majority will be asymptomatic. So in 2 weeks herd immunity is possibly achievable at this rate.
2) A large proportion of people will try to defer seeking help till after Eid. But, soon after Eid, hospitals could see a flood of patients leading to ultimate collapse. This is the most likely scenario. One way to prevent this is by having Law Enforcement Agencies enforce strict mask-wearing by everyone. Per leading epidemiologists who have been campaigning against Lockdowns since day 1, nations that enforced lockdowns like ours are at increased risk of collapsing from increased numbers soon after lockdowns are opened too quickly instead of gradually. This is because 2 months of restrictions have lowered the immunity of people. Now when they go out un-protected without a mask getting exposed to asymptomatic carriers, their chances of contracting COVID19 are higher. So it is important that authorities do their job properly in ensuring that for at least 3 weeks, all Pakistanis wear a surgical mask (if asymptomatic) & a N95 (if symptomatic). This will decrease the rate of transmission significantly by 70% per latest study. SOPs must be observed strictly by the book. No ifs & buts about it.
How to Prepare Healthcare system;
Here is a concise guideline on what to do emergently to prevent a collapse;
1) Karachi is most likely expected to be the epicentre in Pakistan because it is mostly vertical & large populations crowded in small spaces. We need to ensure we have adequate healthcare facilities in Karachi. If not, we need to set up at least 3 field hospitals in the city.
2) SOPs must be observed not just in Bazaars but in residential communities especially apartment buildings as well
3) Lahore, Peshawar & Quetta must be on high alert in all government hospitals
4) Be prepared to nationalise all local private hospitals if the number of hospitalisations increased
5) Increase ICU capacity in all metro cities.
6) Prevent crowded triage areas to stop dissemination of disease in hospitals.
7) Try to treat COVID19 out of the hospital setting with tele-health, mobile phone health, OPD clinics (could be set up in containers in various districts of cities.
8) Ask China to provide medical experts including doctors, nurses because we may need more when the numbers increase.
9) Focus on lowering the mortality in this vulnerable period before herd immunity takes effect.
10) Goggles, PPEs, N95 masks must be worn by all hospital staff at all times.
11) Try to use High flow Nasal Cannulas, BiPAPs & CPAPs & use ventilators as the last resort.
12) Start Hydroxychloroquine on all positive cases for 5 days immediately on diagnosis.
13) Use Hydroxychloroquine, Azithromycin, Zinc Sulfate in hospitalised patients if no contraindications.
14) Use Remdesevir in hospitalised patients if no contraindications.
15) Use convalescent plasma in critical patients
16) Use Anticoagulation with heparin in critical patients if no contraindications
17) Get more dialysis machines. Many patients develop end-stage renal disease & die due to lack of dialysis machines.
18) Ensure you have adequate Oxygen reserves.
19) Prepare Morgues, burial grounds, body bags, refrigerated trucks
20) Continue to raise awareness & tell people to restrain from going out unless needed for at least 3 weeks after the lockdown opened. Reason is that people in this timeframe are most vulnerable to contract it & hopefully within 3 weeks, the virus will wear off via herd immunity &/or natural means
21) Place large over-head Sanitisers in all small & large Bazaars.
22) Give people free hand santizers & masks ( Make the traders association responsible for giving these free to all incoming customers)
23) In NY, people mostly died at home. Again, implement SOPs in all small Muhallah/Apartments/Slums.
24) Ask people to take a pinch of Kalonji everyday.
25) Hold all elective procedures & surgeries in all hospitals for at least 10 days after Eid.
26) Try to stop any crowding in public places.
Consensus
There is a lot of disunited approach in Pakistan. Sindh Government & Federal government are not on the same page. Despite having strict lockdown extended by PPP, numbers in Karachi are the highest. There has been media leak that some officials have made lockdown profitable for them by accepting bribes from various traders in exchange for allowing them to keep their shops open discreetly. This kind of approach will only put fuel in fire. Job of SOPs administration must be handed 100% to Pakistan Army that is highly respected by the masses. A national consensus must be publicly issued on current plan of care. Every day we must have the flexibility to make amendments or addendums to this plan as the situation evolves. But, we as a nation must learn to re-open our markets under strict algorithms of prevention & protection. Prolonged lockdowns will not just hurt the economy but they are now being implicated as precipitating compromised immunity leading to worsened mortality.
-Dr FAB, MD
drfabmd.com
