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May 31, 2020

Critical care for Covid patients


May 31, 2020

The struggle against Covid-19 in Pakistan has entered a new phase. The attention must now switch to ensuring how tailored containment measures and judicious decision-making at the local level can be deployed to ensure that the supply of critical care remains ahead of the rising demand.

The state, it seems, has exhausted all means at its disposal to substantially contain the spread of the novel coronavirus across the length and breadth of the country. While the debate on their efficacy and effectiveness will continue, it is important to take stock of key measures taken to date, analyze where we stand and suggest a way forward.

High level decision-making bodies such as the National Coordination Committee (NCC) and National Command and Operations Center (NCOC) were established for collective decision making. Lockdowns were enforced throughout the country. The number of BLS Level 3 labs, required for coronavirus testing, was increased from 8 to 70. An elaborate test, trace and quarantine (TTQ) system was established in each province. Latest technology, including surveillance systems used by the intelligence agencies, was deployed to make TTQ more effective.

Dedicated Corona wards were established at all major hospitals and a public awareness campaign launched to inform citizens about the impending dangers. Relief packages for the poorest sections of society and various critical sectors of the economy were announced to mitigate the immediate economic fall out of the pandemic.

There were several shortcomings in policy formulation and implementation too. All stakeholders, especially the federal and provincial governments, were not always on the same page. Powerful interest groups, such as clergy, industrial elites and later traders and transporters were able to obtain key concessions. The assessment of risk posed by the pandemic to public health differed and affected the strictness of lockdowns. Testing remained below par and very little community testing was done to ascertain the actual spread of the virus at different localities. Personal protection equipment (PPE) remained in short supply for frontline respondents, including healthcare professionals and police personnel.

Despite these shortcomings, government efforts can be credited for slowing the spread of the disease. However, as the appetite within both state and society for containment measures such as lockdowns draws down due to economic reasons, the rate of infection is expected to rise considerably. So the question is: what should the primary public policy objective be at this stage and how should the government go about it?

The ultimate measure of the government’s performance from now onwards will be its ability to provide critical care to everyone who needs it over the next few months.

At the time of writing this article, the number of patients requiring critical care in Pakistan remains low. This is probably due to the slow rate of infection as a result of containment measures and the demographic realities. The number of people over the age of 65 (considered at much higher risk of developing Covid-19 related complications) is just 4.3 percent in Pakistan, compared to over 23 percent in Italy. Nevertheless, WHO data shows that around 20 percent of Covid-19 affectees require hospitalization. Even if this percentage is lower in Pakistan, the situation will be much worse given the scarcity of hospital beds available in the country against the tens of thousands who will need them.

The provincial governments must take immediate measures to cope with the expected surge in demand for critical care.

First, advanced data modelling must be used to forecast the demand for critical care in every district. This must include profiling of citizens with attributes that make them more vulnerable to Covid-19 related complications and estimates of percentage of population in each district that fits that criteria. This does not of course mean that all the people with such a profile will get infected at once. It is therefore important to ascertain the rate of infection in each district to see what percentage of vulnerable people may require critical care at a given time.

Second, a complete assessment and inventory of hospital (and ICU) beds, isolation wards, ventilators and numbers of medical staff dedicated to the Covid-19 response must be made. These numbers must be compared with the actual and forecasted numbers of citizens requiring critical care in each district and monitored on a daily basis. Efforts must be made to beef up the supply of equipment and hospital beds in areas where most needed. It is also critical to save medical professionals from infection to avoid low morale, shortage of personnel and unreasonable workload.

Prudent judgement is required to decide the level of care needed for each patient. As critical care becomes premier, any perception of discrimination along various social fault lines can have serious consequences for social cohesion in the country. Consideration must also be given to the effect of these measures on non Covid-19 related health conditions that need critical care. Furthermore, stringent security measures are needed at the healthcare facilities so that the staff can perform their duties free from any intimidation and undue influence.

Third, rather than blanket country or province-wide lockdowns, such containment measures should selectively be enforced in districts (or tehsils) where projections show constant narrowing of critical care demand and supply curves. This will incentivize citizens (including traders, mosque imams, and managers in other occupation groups) to strictly follow SOPs in order to avoid lockdowns.

Keeping the supply side ahead of the demand curve through measures mentioned above must be the key policy objective for the government under current circumstances. We may not be able to save every life, but no life should be lost without a fight.

The writer is a public policy analyst based in Islamabad.

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