Dr Yasmin Rashid :
Pakistan has surged to global spotlight for effectively controlling the Corona Pandemic. Notwithstanding the recent increase that marks the emergence of the second wave, the dramatic decline in the number of cases till October 2020 is being widely acknowledged by international experts as an ‘amazing success story’.
World Health Organisation (WHO) chief Tedros Adhanom Ghebreyesus praised Pakistan’s response in his Article in British newspaper The Independent recently saying the country has ‘suppressed the virus so that, as the country stabilises, the economy is also now picking up once again, reinforcing the lesson that the choice is not between controlling the virus or saving the economy; the two go hand-in-hand.’
Similarly, a study by UNICEF and International Policy Centre for Inclusive Growth (IPC-IG) acknowledged Pakistan as one of the top-ranked countries in Asia with the highest number of responses to Social Protection amid Corona Pandemic. The joint study assessed social protection response in Asia focusing on an extensive mapping and overview of how social protection measures were deployed by the countries in Asia and the Pacific region in response to Covid-19 crisis.
Former US Treasury Secretary and renowned economist Lawrence Larry Summers said recently that had his country handled the Pandemic as well as Pakistan, it could have saved them in trillions of Dollars. Similarly, Indian opposition leader Shashi Tharoor said, “We look with envy across the border (Pakistan) because you chaps seem to be having a rather pleasant time of it in terms of being able to return to normalcy.”
Punjab comprises 53 % of Pakistan’s total population, yet the province accounted for just over 31 % of Pakistan’s total reported cases with 21 deaths per million against country’s average of 31 deaths per million (India has reported 89 deaths per million) till October. Punjab’s cases stood at 950 per million against country’s average of 1507 whereas India was close to 6000 cases per million. As these figures intrigued a lot of people, it becomes important to share some key points of our response.
Before we explore the impact of some strategically important interventions that defined our response, let us recall that an Imperial College Study had predicted a disaster for us by June 2020 projecting some 22 million cases by the end of the month. Although I have always had reservations over Artificial Intelligence-based Spatio temporal micro-simulation models, yet I admit that the projections gave me many a sleepless night. Even for a potentially biased and exaggerated projection, half the figure meant a disaster we could ill afford. Luckily things did not turn that way.
As we now prepare to battle the second wave, it is important to recall that cases in Punjab had slumped to a few dozen by end of second week of October with occasional yet infrequent increases on certain days. In our biggest spotlight Lahore, the High Dependency Units and ICUs had nearly emptied out. Just as the Pandemic returns back with a vengeance, we need to stay circumspect and vigilant. Laxity may result in return of complete lockdowns. Europe has seen a steady rise in cases in October as France and Germany have re-imposed national lockdown.
This article is only an effort to draw a low-down on our response. As each component requires an elaborative feature on its own, only key events have been documented here.
This article (s) covers following areas for a common reader:
- Develop a timeline-based perspective on developments and response
- Enumerate strategic interventions
- Identify Lessons Learnt from the Pandemic
Our response to the Pandemic began soon after Wuhan outbreak in December 2019. We had ramped up preparations around the time when WHO had only officially acknowledged the reports of “pneumonia of unknown etiology” in Wuhan on 3rd January, 2020. On ringing alarm bells, unwavering commitment was assured right from the highest offices. Our Special Committee, constituted on directives from Chief Minister held its first meeting 10th January, barely a week after WHO acknowledgement. The committee, with two Provincial Ministers, secretaries of the two health departments and Chief Minister Office representative, sat together to mobilize state resources on war footings.
The Special Protection Unit, Civil Aviation and Rescue officials were all called up to devise an integrated provincial response, devise protocols for diagnosis, quarantine and treatment. Just as Iran reported its first case on 19th January, less than a fortnight after our first meeting, we knew that the Pandemic was knocking our doors. Within two weeks, two of our immediate neighbors, Iran and China, had become global epicenters.
By 30th January, when the WHO officially declared Corona as “public health emergency of international concern”, we had already developed a robust surveillance system at airports with simultaneous preparations for isolation and quarantine arrangement for suspected and confirmed cases. Officially, Punjab announced Medical Emergency on 12th February, the same day when the WHO officially gave the disease its current acronym COVID-19. By this time, our Isolation and Quarantine facilities had already been made functional at the 400-bedded PKLI, 250-bedded Tayyip Erdgon Hospital in Muzaffargarh and 250-bedded Institute of Urology in Rawalpindi. All other hospitals in province were put on high alert. At the same time, work on provision of ventilators and necessary supplies started for hospitals already identified for the Pandemic.
Around the third week of March, Italy was already devastated by a major outbreak in Lombardy region with daily death toll reaching 1000. The world was in awe and shock as the virus brought the best health healthcare systems in the world to the brink of collapse. For resource-starved countries like ours, this was a moment of serious concern. Pakistan’s first case was reported on 26th February in Karachi and the second was reported from Islamabad, both patients returning from Iran. As more cases continued to emerge over the next two weeks, it started getting clear that majority of cases had travel history to Iran although some returned from Syria and London. Our lab team also confirmed later through viral genotyping that over 90 % cases were of Iranian circulation and the remaining comprised of European circulation.
Our strategy, adopted globally back then, was to quarantine the suspected and confirmed patients to stop community spread. In view of this, we developed Quarantine facilities to isolate Zayereen returning from Iran.
Punjab reported its first lab confirmed case on 15th March, nearly three weeks after first case of Pakistan, the gap affording us an opportunity to prepare well for the response. We were able to develop quarantine facility for Tablighi Congregation members who gathered at Raiwind on 10th March. Contrary to our repeated requests, the organizers insisted on holding the congregation which acted as a super-spreader event as 539 confirmed cases were later linked to it across the country.
Another worrying development the start of local spread as some 50 participants were admitted to a quarantine centre in Kasur, including five Nigerian women. Global situation started getting much worse. Italy recorded 6557 cases on 21st March with death toll nearing 1000 a day and the worst part was that health workforce was getting infected. By 31st March, Punjab reached 708 cases, a worrying number yet still under control. We constituted the apex technical forum for the Pandemic: Corona Expert Advisory Group, debuting its work with development of algorithm for Case Management on 27th March.
The Corona Control Room in the Primary and Secondary Healthcare Department served as Pandemic nerve centre. Back then, home isolation was not announced as a policy, hence a Patient Tracking System was developed which soon evolved to a complete Trace, Track, Quarantine Unit. Given the stigma and trauma attached with it, we also set up a psychological support helpline for patients requiring psychological counseling.
Strategically, the timing of our decision to close down public gatherings especially educational institutions was instrumental in maintaining a control over key Pandemic variables. We decided to close down shopping malls, markets, parks and public gathering on 24th March. Very much like the rest of the world, we did not know how the virus would behave in summers, yet claims of some scientists, who insisted on temperature effect due to lipid outer, offered some silver lining about low transmission rate in summers. This gave us an opportunity to buy critical time and delay the peak as much as possible. Delay, as it later transpired, was key factor as it enabled us to learn from world experience on case detection, contact tracing and clinical management.
April and May turned out to be crucial time as the expediency of the Pandemic pushed us towards developing the ‘Core Capacities’ in our healthcare system we hitherto lacked. These Core Capacities i.e. ‘prevent, detect and respond’ are part of WHO International Health Regulations and are envisaged in Punjab Health Sector Strategy 2019-2029 as well. We had to start from scratch to develop capacities of Crisis Management and Epidemic Response, turning this colossal challenge into a historic opportunity. A milestone at that stage was the improbable task of developing 1,000 bed Expo Center Field Hospital within nine days.
We were able to use this facility as platform to quarantine suspected and confirmed patients with less severe symptoms. Five hospitals (Mayo, PKLI, Nishter, RIU, Tayyeip Erdgon Muzaffargarh) were prepared to meet increasing number of critically ill patients. Only patients showing more severe symptoms were transferred to the designated hospitals having High Dependency Units and the ICUs. In the middle of the Pandemic, we proceeded with the hiring of 10,000 doctors and paramedics to fight the pandemic.
Another milestone was building testing capacity at a fast pace from scratch as the Pandemic progressed. Starting from just three labs in March, we now have over 50 Public and Private Laboratories with the capacity to perform over 14,000 tests per day. Only in public sector, 16 labs were enabled to conduct tests. Indeed, when the first lockdown was introduced on 20th March, we had a cumulative testing capacity of only 1200 tests per day in all public and private labs.
Our team explored labs in Punjab that could be scaled up. The only BSL-3 Lab available back then was the Provincial Public Health Reference Laboratory (PPHR) established at the Punjab AIDS Control Program. We immediately provided human resource so that it could reach its optimum capacity of 3,000 tests per day. My appreciation for the PPHR technical experts for training and helping us scale up capacity of other labs.
We decided to promulgate the Punjab Infectious Diseases Prevention and Control Ordinance to allow the civil administration and health department enforce measures under the national emergency. It was also declared that the government would provide a month’s additional salary to all healthcare workers across Punjab. We also started indigenous manufacturing of Corona virus protection kits along with large amounts of hand sanitizers, disinfectants and antiseptic.
In the wake of lockdowns, another parallel crisis of unemployment and impoverishment loomed. Hundreds of thousands of daily wage earners lost work eliciting state response. Punjab Government announced a financial support package of Rs 10 billion for 2.5 million families of daily-wage earners under Chief Minister Insaaf Imdaad Programme. The support included financial assistance and release of Zakat funds worth Rs 870 million for 170,000 families. We also decided to remove provincial taxes to the tune of Rs 18 billion. The government granted a 90-day imprisonment rebate to prisoners in jails across the province. A transfer plan was made to shift 3,500 prisoners from overcrowded jails to alternate areas to stop transmission in jails. Very much like our healthcare workers, the Pandemic took a heavy toll on media workers who continued to perform their duties during peak days. I salute their professional commitment in times of trial.
Two media houses in Lahore reported around 70% of newsroom staff as COVID-19 positive. Some leading anchors, columnists and showbiz names were also reported as positive. The government immediately announced a package for media workers under which the government pledged to pay Rs 1 million to journalist losing life to COVID-19 with Rs 10,000 as monthly pension to the family of the deceased.
The lockdowns for businesses continued till mid August. We had suspended prayer services as it was established that public gatherings were the main reason for virus spread. Cities most affected by the Pandemic were Lahore, Rawalpindi, Gujranwala, Faisalabad and Gujrat as well as northern cities along GT Road. In South Punjab, the majority of Corona patients were still from two cohorts: Tablighi Jamat and Zayeren (Pilgrims) coming from Iran.
May marked our pre-peak as we placed our system on trial run. As a preamble to the peak, it gave us good opportunity to check the strength of the system. All platforms for patient registration, patient transfers, data sharing & analysis and psychological support were developed and became fully functional.
The three platforms had following roles:
- Corona Monitoring Unit at Primary and Secondary healthcare Department: The Unit served as primary registration point, ensuring follow-up on home quarantine and contact tracing; it also released public information on number of cases
- Corona Special Unit at the Specialized Healthcare and Medical Education Department: It collected and consolidated data from Private and Public Sector Hospitals, produced details of patients in ICUs/ventilators, prepared trends of Ventilator Occupancy and Mortality to provide baseline data for background information to CEAG
- Corona Cell at Mayo Hospital: It Coordinated and facilitated Patients Admissions/Transfers through Rescue 1122 to nearest facilities based on bed occupancy status at different hospitals.
In May, we announced the findings of first sero survey. The survey was conducted in major hotspot Lahore to draw a realistic assessment of incidence. A sample of 12,000 people was taken from different localities of Lahore. Hot spots were identified for smart sampling including media houses and hospitals for testing. The results of these 12,000 samples were extrapolated to entire Lahore and released on May 15. The extrapolated data estimated that in entire Lahore 670,000 people could be infected, still a far cry from the elusive herd immunity. In May Punjab introduced smart lockdowns instead of complete lockdown. We also introduced smart lockdowns in May when clusters and hotpots were identified in the cities and movement was controlled in those areas.
June was our peak month. Punjab reported 50,022 new cases between 1st June to 30th June which constitutes half of Punjab’s total cases in one month alone. We reported 1265 deaths with 20467 recoveries and recorded the highest number of deaths 86 on 24th June followed by 82 on 19th June and 68 on 16th June.
We hit our peak this month following the completion of incubation period subsequent to Eidul Fitr exposure. Our preparations were primed for the impact. The dreaded projections by the Imperial College of London, predicting around 2.2 million fatalities for the country, were made for the end of June. The study had already given me many a sleepless nights. The “twin peaks”, hit the country on 13th June with 6,825 new infections and on 19th with 6,604. These remain Pakistan’s highest number of new infections from Covid-19. For Punjab, 12th June was the pinnacle with 2705 new cases, followed by 9th June with 2641 new cases. The third highest was on 19th June with 2538 new cases in one day. Incidentally, our highest recoveries for one day 8,014 were recorded on 12th June and second highest 3822 were recorded on 27th June.
June spike owed much of its origin to the rampant disregard for Social Distancing by people around Eidul Fitr on May 24. We had opened markets briefly after reaching understanding with traders’ bodies on assurance of compliance with SOPs. Markets were thronged to full capacity in apparent violations of the SOPs. Mosques remained packed due to Ramazan and Eid days as well. We allowed partial opening of businesses, yet that came at a heavy cost as people flouted the SOPs. There were repeated reports of shopkeepers doing business while keeping shutters down. Post-Eidul-Fitr surge began as June arrived.
Between second and third week of June, our designated hospitals were filled close to their capacity.
We closely monitored the situation and started preparations for the next stage, however, cases started to decline by last week of June. There were occasional complaints of shortages of oxygen, for a brief time a panic around the availability of Tocilizumab and news of people not approaching healthcare facilities owing to the stigma.
The declining trends continued in July as number of new infections and the patients at ICUs continued to report a steady decline. We had 205 patients on ventilators on 21st June and within one month, the number slumped to 75 on 20th July. Countrywide, figure showed similar trend as on 3rd July, just above 11,400 people recovered, while over 4,000 new infections were reported. On 17th July, more than 14,700 people recovered, while less than 2,000 new infections were reported. A week later, on 24th July 24 we recorded over 16,800 recoveries against 1,487 new cases. The tide was changing rapidly. People were being discharged from hospitals in droves, while new arrivals slowed to a trickle. More importantly, Active Cases dropped rapidly.
July provided the much needed reprieve as cases started declining gradually. Active Cases peaked to 40,000 in two weeks between 19th June to 4th July, recording a sharp plunge afterwards. As the gap between the number of recoveries and new infections widened significantly, the number of tests started declining. Accordingly, test Positivity Ratio (number of people testing positive from all tests performed) started coming down. On 1st July, Punjab recorded highest number of new cases for the month with 1478 cases that continued to decrease and by month end, on 30th July, cases had plunged to just 218. As daily recoveries rose, demand for Ventilators and for Pressurized Oxygen at the High Dependency Units and ICUs dwindled greatly.
Overall, recoveries continued to outnumber new infections and on 24th July, 12802 recoveries remain our highest number in a single day. With Active Cases going down, other indicators i.e. New Infections, Fatality Rates and daily tests showed similar declining trend. Starting the month with 35 deaths on 2nd July, Punjab recorded no deaths on 26th July and only two deaths on 30th July.
As we learnt more about the efficacy of the Smart Lockdowns model, we added more areas extending them to posh areas like Model Town. The trend of hospitals emptying out continued in the last week of June. As of 1st July, 85.1 % beds were vacant. In Isolation Wards, 89% beds were available, in the High Dependency Units in entire Punjab, 77.6 % beds were unoccupied and 67.8 % ventilators were available.
July was tragic in many ways as well as we lost Vice Chancellor Nishter Medical University Professor Mustafa Kamal Pasha who breathed his last on 15th July. Professor Mustafa Kamal Pasha was a committed and dedicated professional and was instrumental in developing testing and treatment facilities for COVID-19 patients in Multan. Globally, Covid-19 became a disaster at same time period in rest of the world in July. Only in the United States, cases climbed from 1.2 million to over 1.6 million by July 4. Overall, the US crossed 8.5 million Cases as of on 21st October.
In August, trends from key indicators clearly established that Punjab had managed to significantly slow down the transmission rate. Eight days of August passed without a death, however, there were occasional scares of a comeback. The highest number of infections for the month came on 8th August with 276 cases. On 30th August, we recorded merely 28 new cases. Our recoveries had already peaked on 4th August at 2605.
In first week of August, we had formally ordered the resumption of all routine services in Public Sector Hospitals. The start of the month marked incubation period after Eidul Azha sparking a fear of a possible spike. That spike did not come even though compliance with SOPs at cattle markets remained worrying low. September saw steady decline as cases remained inside double figures mostly. By the end of the month, a slight increase was witnessed in the new infections reaching 187 on 26th September, highest for the month. Overall, there were 10 days in the month when no death was reported. As we had decided to open all educational institutions and marriage halls, the slight increase was somewhat expected.
Key Factors:
The first key factor was Ownership and Oversight by the highest offices from the government. The top-down model of governance to our advantage and enabled us to develop institutional framework for laying the foundation of a robust response mechanism. Starting from the National Command and Control Center, provincial response was led by the Chief Minister himself through Cabinet Committee that met on daily basis in early days.
This was followed by technical/advisory bodies i.e. Corona Experts Advisory Group (CEAG), Corona Monitoring Units in Department (s) translating into vertical and horizontal multi sectoral collaborative mechanism synergizing technical and administrative arms of the Government. Then, to take key decisions on treatment and review epidemiological trends, CEAG amalgamated experts from respective fields. The CEAG provided insight for effective response including trends in population clusters incidence, severity, geographical vectors and trials for new therapies.
The second key factor was Timeliness of response: All countries credited with successful control of the Pandemic. i.e. a China, Uruguay, Japan and New Zealand, have one thing in common, timeliness of response. As we did not have a robust healthcare system at par with the developed nations, our margin for error was already much limited. Even though the Pandemic hit us a touch later, we were among the first to close down educational institutions and ban public events and gatherings. Similarly, moving ahead of time and developing facilities for patients with No Symptoms, Mild Symptoms and Moderate to Severe Symptoms was the decisive factor.
Third was development of Response Platforms to organize and regulate patient registration and follow up. The Corona Monitoring Cells in Department, Trace, Track and Quarantine Unit and Patient Transfer System helped us streamline the flow.
Fourth was the development of mass isolation and quarantine arrangements in the early part the Pandemic that controlled the spread in the winter helping us take the peak into the Summer.
Fifth was the development of SARS COV-2 Testing capacity at a large scale through setting up of BSL-3 labs across Punjab. Till date, we have made functional 16 BSL-3 labs in Public Sector alone.
Sixth was reliance on evidence-based decision making. We continuously analyzed data received from three platforms and devised SOPs accordingly. For example, we analyzed that cities around GT road between Lahore and Rawalpindi were reporting most number of cases therefore these cities were under the kaleidoscope. Then we identified hotspots in those cities and went for smart lockdowns with an aggressive Contact Tracing Program.
Seventh was Resource Provision & Mobilization to ensure uninterrupted supplies to frontline workers. This included arrangements for a wide range of necessary equipment from PPEs to ventilators, Oxygen supplies, disinfection and ancillary material along on fast-track basis without compromising on quality.
Eighth is Training and Motivation of our doctors, nurses and paramedical staff serving on the frontline. Throughout the Pandemic mortality among healthcare professionals continued to deliver shocks. This could be so de motivating yet I was pleasantly surprised at the resilience of courage of our professionals.
Ninth is creativity and innovation for development of alternate platforms to replace conventional treatment. The first Telemedicine Unit used latest technology to provide online OPD services.
Tenth is the development of Social Safety Net to support the marginalized population and daily wage earners. The Government brought together philanthropists, NGOs and public relevant sector institutions on one platform to channelize contributory and of non-contributory assistance to vulnerable families and individuals.
Separately, young people are known to be less severely affected or less likely to get critically ill. Regions and countries with younger populations have generally performed better. Africa’s daily new case count averaged around 16,000 compared to over 100,000 in Asia. The specific reasons as to why young population is less susceptible is still being studied the world over.
Nearly 50% of Punjab’s population is below 25 with 42.52% less than 15 years of age. We have only 4 % population in the over-65 age group category, the most vulnerable age group. Africa for example, known to be the youngest continent on the planet with 60 % of the population below 25, have seen very low rates of incidence and severity. Over a period of last eight months, our incidence has varied between 30 % to 34% in the 31-45 years age group, between 21 % to 24 % in 45-60 years age group and stayed around 10% in 61-75 years age group. Similarly, incidence remained around 30% in 16-30 years age group from March onwards. This data indicates that around 70% infections are in below-45 age group where severity of symptoms is less likely. However, age group alone does not determine the course if not capitalized smartly.
In neighbouring India, the population age distribution is not much different to that of Pakistan, yet incidence, severity, case fatality and transmission rate are not same as ours. State interventions have to be carefully planned to make the most of favorable variables.
The Pandemic presents certain caveats that we as a nation have to learn.
Foremost is that health, economy and development are interwoven and integrated. The emerging concept of One Health is the pivot around which we need to develop our larger development edifice. A modest beginning will be to devise workplans with defined targets to achieve the larger UN Sustainable Developments Goals.
The writer retired as Professor of Obstetrics and Gynecology at King Edward Medical University Lahore and currently serves as Health Minister of Punjab.
Special acknowledgements for Sajjad Hafeez, Manager Minister’s Delivery Unit, for assisting me with background data and insightful perspectives.
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