Let's talk strategy

April 12, 2020

Pakistan must come out of denial and implement a plan that fits its resources

Thus far, five countries across the globe have recorded over 100,000 novel coronavirus (Covid-19) cases each. Pakistan has less than 5,000. Pakistan’s lower numbers are indicative of a weaker strain of the virus circulating among people with a stronger immunity due to the BCG vaccine and repeated malaria exposure. Right?


In America, we wasted the month of February, thinking we only had 100 cases (not realising that we had performed less than 500 tests). Similarly, we attributed our “success” to various local factors, not realising that correlation is not causation. By March, America started testing. By March 10, Covid-19 cases soared to 1,000; by March 20, 10,000 and by early April, over 350,000.

So, what changed? Our mindset.

America came out of denial. Pakistan must do the same and implement a plan that fits its resources.

Having worked in the United States as an infectious disease expert for over two decades, and having managed the outbreaks of SARS, H1N1, and Ebola, I know what works in America may not work in a resource-limited Pakistan. My initial recommendations, therefore, are aimed at what’s achievable, instead of what’s desirable.

Here are my 10 points to establish an affordable defence against Covid-19:

Make people feel safe

People have fears: “What if I test positive? Who will feed my family? Who will pay the bills? How long will it last? Will I die?” Acknowledge the magnitude of these fears. Leaving denial doesn’t mean we enter panic. Stay in the middle, where safety and preparedness lie.


Communicate safety clearly and repeatedly. Reassure patients that a Covid-19 positive test will not result in the police showing up at their home; they will not be held in a hospital or quarantine facility against their will. They won’t be evicted from their homes. Debunk social media-generated myths on media. Let infectious disease and public health experts drive the scientific narrative. Let the government explain the public welfare initiatives.

Wear facemasks

Operationalise safety by encouraging the public to wear a regular surgical mask (not the bulging N95 mask) while outside the house. Facemasks prevent the spread of infectious droplets from the wearer to people in the surrounding. During the SARS outbreak, 90 percent of people in Hong Kong (a densely populated place) wore such masks in public. If people cannot find or afford such masks, they should make one from a double-layer of any spare cotton cloth in their homes.

Strategic lockdown

Pakistan is not China or America. Blanket lockdowns may perpetuate panic and have catastrophic consequences for millions of people who barely survive on an eat-what-you-kill model. Effectively locking down the inner cities or slums isn’t possible either. So let essential government and private sectors continue to run while stopping the torrent of weddings and funerals, sporting and musical events, religious services and classroom teaching for at least 3-4 weeks. Then reassess.

Protect the frontline

Ensure an adequate supply of personal protective equipment for healthcare workers. Reserve N95 respirator masks and face shields for healthcare workers only. To mitigate shortages, inspire garment factories to make gowns and masks instead. This issue is particularly acute in Pakistan, which has only 0.5 nurses and 1 doctor for every 1,000 people; developed nations have 3 and 10 times more, respectively.

Test and trace

Iran – a resource-limited country of 81 million people – claims to have tested 33 million people. Pakistan, a country of over 200 million people, should at least be performing 10,000 tests a day for the next few weeks. Test everyone who comes to a clinic or hospital with a fever, sore throat, cough, shortness of breath, and an acute loss of smell or taste. Trace and then test the family members of Covid-19 positive patients. Statistically, 10-15 percent of them may catch the infection. Then repeat this process with friends and keep digging deeper as per the principles of contact tracing.

Let infectious disease and public health experts drive the scientific narrative.

Let the government explain the public welfare initiatives.


Whenever possible, instead of draining limited hospital resources encourage Covid-19 positive patients to stay at home. Pakistan has 0.6 hospital beds and 0.01 critical care beds per every 1,000 people; developed countries have 10-20 times more. While at home, patients should stay in a private room and use a separate bathroom for 10-14 days. Where families are large and homes are small, to protect family members, put up a screen, or hang a thick cotton curtain from the ceiling to divide the room. If patients walk around, they must do so while wearing a facemask.

Nebuliser treatments

Nearly 10 percent of Pakistan’s population suffers from asthma. Many use nebuliser treatments, not knowing that this routine procedure may spread thousands of viral particles into the air. Since up to 25 percent of Covid-19 patients may not have overt symptoms, all nebuliser users must use a separate room for their treatment, and that area should be cleaned afterwards.


Instead of buying more ventilators, we should be having some hard policy discussions. Studies show that survival rate of Covid-19 patients on a ventilator is less than 50 percent. In Pakistan’s infrastructure, that number is likely to be much lower. How then, should we be prioritising these scarce resources? How many thousands of masks can be purchased in the price of one ventilator? How do we balance the needs of non-Covid-19 patients who may need a ventilator – and have better chances of survival – against a Covid-19 patient?


Think innovatively. Can doctors make a video or voice call to a coughing patient from another room to reduce their own risk? Can an app be developed to track the whereabouts of non-compliant Covid-19 patients instead of tying them to a hospital bed? Can we detect Covid-19 community hotspots by using CCTV footage? Engage the tech industry and challenge them to find cheap, creative solutions.

In the end, no recommendation will succeed – even in affluent countries – unless the nation becomes as unified as the virus is. The virus doesn’t ask if you are a man or woman, rich or poor, liberal or conservative, Sindhi or Punjabi, a supporter of the PTI or PML-N. It only asks: are you human? Covid-19 is united against humanity, not just Pakistan. So, all of Pakistan’s citizens must unite against it. Pakistan’s government and medical experts are not perfect, and their decisions won’t be either. But uniting behind their message is the most affordable treatment, and setting aside our differences is the most powerful vaccine – and it’s available now.

Let’s use it.

The writer is the chief quality officer and chief of infectious diseases at the University of Maryland-Upper Chesapeake Health. He tweets at @FaheemYounus and can be reached at fyounus@umm.edu

Pakistan must come out of denial and implement a plan that fits its resources