HEALTH 1 -15 June 16-30 June

Website: www.ihsr.pk Written ,compiled and designed by Ali Ashar Anjum 1 A fortnightly report on Health (1-15 June, 16-30 June) FROM THE FRONTLINE

Number of Covid More than 100 doctors battle coronavirus in Faisalabad patients in Balochistan The scourge of Covid-19 is affecting the treatment of the patients as more space may reach 100,000 doctors and more than 100 of them in was required to treat the patients. three government hospitals – Allied, DHQ FMU VC Dr Zafar Chaudhry said actually A top health official of Balochistan and General Hospital Ghulam Muham- no patient had been shifted from the has raised an alarm over the surge of madabad – are suffering from the dis- General Hospital which is a tehsil level coronavirus infections in the prov- ease. facility without adequate arrangements ince, warning the cases could in- Doctors alleged the district administration for treatment of serious patients. He said crease to over 100,000 within the was responsible for such a state of affairs. this state of affairs was there even before next few months. Corroborating their claim, they said new serious virus patients were referred to “From July to September we are ex- wards had been set up at the Allied and the DHQ and Allied hospitals. On March pecting coronavirus cases to peak DHQ hospitals without precautionary 16, he said, it was decided that the coro- and the situation could become dan- measures although sufficient beds were na patients would be managed at the gerous,” said Dr Saleem Abro, Direc- available at the General Hospital Ghulam General Hospital so as to contain the dis- tor General Health Balochistan, at a Muhammadabad. The General Hospital ease. Six ventilators were shifted to that press conference held on 12 June. dedicated for the Covid-19 treatment has infirmary from the Allied Hospital. He said “About 40 per cent of the population 250 beds and only 60 are being occupied. during the last three weeks the number in the province is currently infected,” Pakistan Medical Association Faisalabad of serious patients rose exponentially and he added. “People are also not in- chapter Secretary Dr Muhammad Irfan there was a danger that we might lose forming the government about in- said a majority of the doctors were not patients who could be saved if more HDU fected patients and deaths are occur- provided the personal protective equip- beds were available. He said the decision ring in various parts of Balochistan,” ment and they, therefore contracted the to manage increasing number of serious said Dr Abro. “If people do not strict- virus. The spread would not be controlled patients at the Allied and DHQ hospitals ly follow the SOPs, then the infec- without provision of PPE, he feared. was not taken by the VC but it was the tions could reach over 100,000,” he An official of the (FMU) said the authori- recommendation of Covid management added. ties were perturbed due to the health of team comprising heads of medical units According to DG Health, 79,000 peo- doctors and paramedics. He said wards of FMU. (Saleem Mubarak, Dawn, 3 June ple have so far been screened for had been set up in two hospitals for the 2020) Covid-19. He lamented the fact that even though health authorities had Amid coronavirus spread, health experts warn recommended a complete lockdown but their warnings were ignored with against self-medication the lockdown converted to a “smart” lockdown. He said infections were Amid worsening Covid-19 situation, cases trend of self-medication among the gen- increasing rapidly across the country. of extensively drug resistant (XDR) raised eral public as many people avoided vis- (Dawn, 14 June 2020) concerns among health professionals iting hospitals or laboratories on doctor’s who have called upon the general public advice these days. Doctors stress the standard forms of this medicine would to practice safe eating and drinking hab- need for correct diagnosis as symptoms also be available in the market and their its, vaccinate against the disease and, last of dengue, Covid-19 and XDR typhoid are use might also cause drug resistance. but not least, avoid self-medication. largely similar Seconding his opinion, senior physician “While Covid-19 remains our major con- “There is an antibiotic drug called Dr Altaf Khatri, who runs a private clinic cern, we are also getting patients of den- azithromycin, the only oral medicine we in the old city area, said azithromycin gue and XDR typhoid. At times, patients have so far to treat XDR typhoid. Now, was prescribed in different ailments and report with multiple health issues, mak- this medicine is also being given to sec- people must not use it without prescrip- ing diagnosis and treatment challenging ondary Covid-19 patients (who develop tion and follow its recommended dose, if as symptoms of dengue, Covid-19 and pneumonia). We fear that Covid-19 pa- it’s prescribed.“A majority of Covid-19 XDR typhoid are largely similar,” said Dr tients with mild illness may use it without patients have either mild or no symp- Abdul Ghafoor Shoro, a senior family prescription and develop resistance toms [and do not require this medicine]. physician at the Aga Khan University Hos- against this medicine. He added Doctors should provide relief to patients pital (AKUH). “Doctors should also exercise caution as after seeing the severity of their symp- It’s important that a physician made the any misuse of this medicine may lead to toms. They should guide patients and call correct diagnosis and ruled the possibility drug resistance,” he said, adding that them for a follow-up,” he said, under- of other diseases before focusing on since it’s an oral medicine it’s easy to be scoring the need for a holistic approach Covid-19, he added. administered especially to children with in treatment. Explaining how drug resistance may de- typhoid unlike the other drug for XDR (Faiza Ilyas, Dawn, 17 June 2020) velop in this particular health situation, typhoid. he said Covid-19 fears and misinfor- Given the spike in Covid-19 cases, it mation on social media had increased the won’t be unrealistic to assume that sub-

2 A fortnightly report on Health (1-15 June, 16-30 June) FROM THE FRONTLINE Hospitals in Karachi, Lahore running out of space as cases rise

With hospitals overwhelmed and a sharp Dr Muhammad Shamvil Ashraf, an rise in the number of deaths, Pakistan's official of the Indus Hospital in Kara- delicate health system is bracing for an chi, confirmed his facility was al- imminent peak of novel coronavirus cas- ready running at "peak capacity". es. He added The number of patients Government officials claim the situation are growing way higher than the is "under control," but health authorities number of beds. Sometimes, we do believe the already stretched health sys- not have space to keep the patients tem is unable to handle the lurking influx in the emergency [ward]," he said. of Covid-19 patients. "At this stage, my only advice is In the country's two most populous follow the safety guidelines because cities of Karachi and Lahore, hospitals if the numbers continue to grow are already struggling because of a sharp like this, we won't be able to handle technicians have already gone into self- increase in Covid-19 patients in recent them." isolation after getting infected by the weeks. Some major private hospitals are virus across the country. Young doctors turning away patients because of a Worst is yet to come with no required experience are being shortage of beds. The country's Covid-19 tally has reached pitched to handle ICUs, and ventilators "Most of the hospital beds have already 95,458 with 1,954 deaths, landing it at in several hospitals to bridge this gap, been taken by patients, limiting our abil- the 17th spot worldwide in terms of which is not good at all," he said. ity to handle the influx of Covid-19 cases, coronavirus cases. Pakistan is the worst The government recently launched a mainly in the big cities," Dr Faiyaz Alam, hit country by the pandemic in the re- mobile application that provides infor- an office-bearer of Pakistan Islamic Med- gion after India. mation about the availability of ventila- ical Association (PIMA), a nationwide Apart from several parliamentarians, tors in hospitals. Dr Asad Aslam, a mem- body of medical professionals, told dozens of doctors and paramedics have ber of the Punjab Corona Experts Adviso- Anadolu Agency. died of the coronavirus. But doctors, ry Group, said the government is in- who have been opposing the lifting of a creasing the number of beds and ventila- prolonged lockdown, fear the worst is tors in state-run hospitals following a about to come. possible spike in Covid-19 cases. "With "June and July are very crucial as we the increment in numbers of patients, expect a sharp rise in already fast- we are increasing the ventilator capacity. increasing coronavirus cases in the coun- “We have reserved 200 ventilators for try," according to Qaisar Sajjad, secre- critical patients in Lahore alone and will tary-general of Pakistan Medical Associa- add 100 more by June 30," Aslam, who is tion. He reportedly said that"I don't fore- also the head of state-run Mayo Hospital see good days ahead vis-a-vis corona- Lahore, told Anadolu Agency. Alam sug- virus cases. They are going to shoot up in gested the formation of mobile health coming weeks," he said, cautioning that units to fight the raging pandemic. the country's already fragile health sys- "Hospitals have no more capacity to ad- tem might collapse following the ex- mit Covid-19 patients. The only option Hospitals running short of beds pected rise in Covid-19 cases. left is to treat them in their homes with In Karachi, home to more than 15 million In addition to choking health facilities, the help of mobile health units," he said. people, and one of the worst-hit cities in the shortage of trained medical staff is Anadolu Agency the country, 15 government, private and adding to the worsening situation, Sajjad ( Dawn, 6 June,2020) charitable hospitals are dealing with observed. "Over 2,200 doctors, nurses, coronavirus patients. The number of and ventilators in those hospitals, according to official figures, are 136. Just 539 beds and 200 ventilators are available for coronavirus patients in Lahore, accord- ing to Punjab's health minister, Yasmeen Rashid. Punjab and Sindh, which make up more than 71,000 of the country's 95,458 cas- es, have slightly more than 14,000 beds for coronavirus patients at state-run and private hospitals.

3 A fortnightly report on Health (1-15 June, 16-30 June) OVERVIEW

Pandemic in Pakistan : OVERVIEW ( 1 June-30 June)

Source: http://covid.gov.pk/stats/pakistan

4 A fortnightly report on Health (1-15 June, 16-30 June) OFFICIAL MEASURES NCOCs Initiatives

Pakis-tan on 5 June witnessed its single-day said the government had a two-pronged death toll crossing the 100 mark with the strategy — focusing on disease spread con- number of cases in the last 24 hours also trol and upgrading the healthcare system surging past 5,000, taking the total number of with effective deployment. infections to 91,365. National Coordination The NCOC, which was established a couple of and Operation Centre (NCOC) bringing over months ago to oversee, coordinate and chan- 15,450 hospitals online to deal with the Covid nelize the country’s resources to overcome -19 pandemic. has obtained the entire the Covid-19 crisis, on 5 June launched an strength and capacity of each and every hos- app called Pak Nigahban to provide infor- pital. The inventory of all these hospitals is mation to the public about hospitals and the shared with the NCOC on a daily basis. The availability of ventilators. This will help avoid relevant medical superintendents have ac- burden on major hospitals. cess to the online facility so that they can According to a press release, 1,110 hospitals change their hospitals’ inventory as and across the country have been linked with the number of patients on them are said to be when necessary. app. The app will be instrumental in providing 306. During last couple of months, the NCOC Special Assistant to the Prime Minister on care in emergency situations and can be managed to get ready the country’s health Health Dr Zafar Mirza updated the forum downloaded from Google Play Store. A link system to meet challenges of the Covid-19 about ‘We Care’ campaign for protection of has also been given on the government’s pandemic and improved testing capacity frontline healthcare workers fighting the Covid-19 website, covid.gov.pk, to download from 400 in March to 30,000 till date. Covid-19 pandemic across the country. Over- it. The app has been launched as part of the The government has also acted promptly to all 20,000 frontline health workers were NCOC’s Resource Management System (RMS) handle the situation and injected Rs50 billion trained in two months through videos, PPE to ensure optimum utilization of healthcare into the health sector, besides giving Rs144bn (personal protective equipment) guidelines facilities against Covid-19. to the poor and daily wage earners under the and provisional course. The RMS system allows the provinces to re- Ehsaas cash distribution programme. Speaking on the occasion, Asad Umar view the facilities available within the hospi- A training programme for doctors and health stressed the need for continuing to hammer tals in their respective areas. Under this sys- workers called “We Care” was also launched SOPs compliance in the masses and said the tem, 15,459 hospitals across the country to impart training to 100,000 doctors and positive outcome of enforcement should also have been linked. This will enable the prov- health practitioners and so far 20,000 of be projected at the forum and in the media. inces to review the facilities available in the them have been trained. Meanwhile, the Moreover, according to information gathered hospitals falling under their precincts, the country has become self-sufficient in masks, by the NCOC from all the provinces, a total of press release said. PPE, sanitisers through indigenous produc- 1,311 markets and 83 industries were sealed The NCOC also launched a WhatsApp 1166 tion by local firms. A system is also being and 2,221 vehicles imp-ounded across the emergency service where doctors and health devised to revive all basic health units (BHUs) country on 5 June over violations of standard workers can register their complaints and and network of dispensaries both in rural and operating procedures (SOPs). Smart lock- other relevant information. urban localities. down was imposed in 848 areas with a total According to the NCOC, presently 1,400 ven- (Syed Irfan Raza, Dawn, 6 June) population of 269,800 people. The minister tilators were available in the country and the

Sindh plans to hire 2,200 doctors to fight Covid-19

The Sindh government on 29 ers, staff nurses, lab technologist and techni- 89 days in the wake of Covid-19. June announced its plan to re- cians; release of funds for the Child Life Foun- “The ventilator management training will be cruit 2,200 doctors in a move to dation, the Trauma Centre, medical universi- provided to the doctors and paramedics and bridge the widening gap emerg- ties; recruitment of new doctors and expan- for this the health department has been di- ing due to the growing number sion of high dependency unit (HDUs) and rected to move a proposal in this regard,” the of coronavirus cases in the intensive care units (ICUs) of the province. statement quoted the chief secretary as say- province after a larger number In an attempt to meet the challenge of Covid- ing. of health workers fell victim to 19 in the province, the Sindh government Minister Pechuho told the meeting that the Covid-19. earlier this month increased the allocation for number of ICUs and HDUs in various hospitals The decision came during a the health sector by 16.1 per cent from were being increased. “Some 147 ICUs and meeting jointly chaired by Sindh Rs114.4 billion to Rs132.88bn in the provin- 834 HDUs are being added in different hospi- Chief Secretary Syed Mumtaz cial budget for 2020-21.In addition to tals, including Civil Hospital, Services Hospital, Ali Shah and Health Minister Dr Rs132.88bn, Rs7bn has been allocated for Lyari Hospital, Gulistan-i-Jauhar Hospital and Azra Pechuho. A statement said nine vertical programmes, including polio Nipa Hospital,” the statement quoted the the meeting was also attended by the secre- control, AIDS and TB, thus making the total health minister as saying. “More than 400 tary finance Syed Hassan Naqvi, secretary allocation for the health sector Rs139.17bn. doctors are currently providing telemedicine health Kazim Jatoi, Vice Chancellor of Dow Despite facing a serious financial crunch, the services. An agreement has also been signed University of Health Sciences Prof Dr Muham- provincial government also increased health’s to hire another 250 doctors for telemedicine. mad Saeed Qureshi and other senior officials. development portfolio. There are 452 rapid response teams con- The meeting, it said, discussed various issues The meeting also decided to release salaries sisting of 1,382 doctors and paramedics of the health department, including release to medical officers, staff nurses, lab technolo- working in the field for coronavirus.” of salaries of newly appointed medical offic- gist and technicians who were appointed for (Imran Ayub, Dawn, 30 June)

5 A fortnightly report on Health (1-15 June, 16-30 June) OFFICIAL MEASURES

Covid-19 prompts over 16pc increase in provincial health budget

In a bid to meet the challenge of Covid-19 in the Sindh Assembly in his budget speech that the province, the Sindh government has in- during the current financial year (2019-20), creased the allocation for the health sector by Rs4bn was allocated as a special grant for the 16.1 per cent — from Rs114.4 billion to Indus Hospital Karachi. The government has Rs132.88bn — in the provincial budget for also allocated Rs500m for the National Insti- financial year 2020-21. tute of Blood Diseases (NIBD). In addition to Rs132.88bn, Rs7bn has been Rs7bn for nine vertical programmes allocated for nine vertical programmes, in- The CM said that Rs7bn had been allocated in cluding polio control, AIDS, TB, thus making the financial year 2020-21 for nine vertical of Cardiovascular Disease (SICVD) is Rs5.14. the total allocation for the health sector programmes to combat/control polio, TB, The SICVDs are situated in Karachi, Larkana, Rs139.17bn. AIDS, hepatitis control, expanded programme Sehwan, Hyderabad, Sukkur, T.M. Khan, Sha- Despite facing a serious financial crunch, the for immunization and others. An amount of heed Benazirabad, Khairpur and Mithi.The provincial government also increased health’s Rs559.4m has been allocated for the TB Con- government has allocated Rs3.6bn for the development portfolio. trol Programme while Rs5.5bn allocated for a Institute of Pir Abdul Qadir Shah Jillani, Gam- In his budget speech at the Sindh Assembly multi-sectoral Accelerated Action Plan for bat. It also allocates Rs1.75bn for the SMBB on 17 June , Sindh Chief Minister Murad Ali reduction of stunting and malnutrition in Trauma Centre in Karachi. Shah said that his government had earlier various departments, including health. The decided to keep the size of development lady health worker programme got Rs1.2bn in Rs5.6bn for SIUT budget for 2020-21 “nearly same as that of the next budget; Rs1.9bn for prevention and The provincial government has also ear- 2019-20”.However, he added, in exceptional control of hepatitis in Sindh; Rs267.9m for marked Rs5.6bn for the Sindh Institute of cases such as health, allocation had been maternal, neonatal and child health pro- Urology and Transplantation in its budget for increased from Rs13.50bn to Rs23.50bn in gramme and Rs2.3bn for EPI Sindh. 2020-21.An amount of Rs6.53bn has been order to meet the challenges of Covid-19 allocated for the Peoples Primary Healthcare pandemic. Infectious disease control hospitals Initiative (PPHI). A sum of Rs2.56bn has been Allocations made for key healthcare facilities An amount of Rs1bn has been allocated for a allocated for the PPP node health depart- across the province: The CM said he was com- 200-bed infectious disease control hospital in ment. Around Rs893.79m has been allocated mitted to providing maximum resources for Karachi; Rs1bn for upgrade and making oper- for extension of services of the SIUT. the health sector. “Health continues to re- ational newly completed 22 health facilities; Rs550.42m has been allocated for the estab- main the third largest sector and for financial Rs234.6m for upgrade of healthcare services lishment of a 25-bed trauma centre at the year 2020-21 total current revenue expendi- for the Lyari General Hospital. Sindh Government Lyari General Hospital, ture is budgeted at Rs139.1bn while alloca- The government has also allocated Rs1.3bn Karachi. The government has allocated tion for development schemes is Rs23.5bn. and 1.12bn, respectively, for the establish- Rs431.13m for medicine of blood cancer; ment of 200-bed infectious diseases control Rs1bn for welfare of HIV/AIDS patients; Covid-19 measures hospitals in Mirpurkhas and Shaheed Benazi- Rs160m for treatment of Thalassemia in vari- An amount of Rs5bn is allocated for Covid-19 rabad. ous health facilities; Rs900m allocated for the response, the budget document says, re- Also, Rs2bn each has been allocated for the Child Life Foundation Karachi; Rs383.87m calling the extraordinary challenge that the establishment of 200-bed infectious diseases allocated for extension of a project for other provincial government has been facing since control hospitals in Hyderabad, Sukkur and cancer diseases and Rs150m has been allocat- February. It said that the government had Larkana. ed for dialysis in various health facilities. established a Rs3bn Coronavirus Emergency An amount of Rs521.1m has been allocated Rs300m has been allocated for the Institute of Fund and released Rs1.11bn for setting up for the health facilities of proscribed organisa- Ophthalmology & Visual Sciences Hyderabad; field isolation centres in the current financial tions which had been taken over by the Sindh Rs600m for the Jacobabad Institute of Medi- year. government. cal Sciences; Rs300m for the Shahdadpur in addition, Rs4.12bn was released to desig- Over Rs10bn for cardio hospitals Institute of Medical Sciences; Rs100m for the nated public and private health facilities for The Sindh government has allocated Rs5.15bn Institute of Physical Medicine and Rehabilita- Covid-19 and Rs1.08bn was provided to all for the National Institute of Cardiovascular tion; and Rs365m has been allocated for the deputy commissioners for providing rations to Diseases (NICVD) in the next budget. The Sindh Health Care Commission. the poor and daily wage earners. The CM told budgetary allocations for the Sindh Institute (Azfar-ul-Ashfaque, Dawn,18 June) Health professionals involved in COVID-19 management to get risk allowance

The Sindh government announced it would spokesman for the Chief Minister House and physicians had been highly demoralised pay one basic salary as ‘health risk allowance’ said on Tuesday. since April this year when the Sindh govern- to physicians treating COVID-19 patients as Health Minister Dr Azra Pechuho has forward- ment had deducted 10 per cent of their sala- well as those working at labs and isolation ed a summary to CM Syed Murad Ali Shah for ries for the coronavirus relief fund.On the centres, saying the postgraduate students the payment of the health risk allowance, other hand, health professionals working in (PGs) and house officers (HOs) would be paid recommending that in addition to the pay- the private sector said they were being sub- salaries of 17 and 18 grades respectively from ment of the health risk allowance to health jected to discrimination and deprived of their March 2020. “The health risk allowance equal professionals in the management of COVID- salaries and benefits as managements of pri- to one basic salary would be paid to all those 19, PGs and house officers would also be giv- vate health facilities were not paying full sala- health professionals who are performing their en salaries equal to the basic salaries of ries to them citing business losses due to duties at COVID-19 treatment wards and oth- grades 17 and 18 respectively till the corona- reduction in the patient load. er facilities, including the isolation centres,” a virus pandemic subsides. Health professionals (The News, 3 June. )

6 A fortnightly report on Health (1-15 June, 16-30 June) NEWS DIGEST WHO says Pakistan meets no pre-requisites for easing restrictions, recommends 'intermittent lockdown'

The World Health Organization (WHO) — in a letter addressed  Schools, workplaces and other essential places should to Punjab Health Minister Dr Yasmin Rashid — has recom- have preventive measures mended that the country impose an "intermittent lockdown"  The risk of importing new cases can be managed to curb the spread of Covid-19, noting that the country doesn't  Communities are fully educated, engaged and empowered meet any prerequisites for lifting restrictions as was done on to live under a new normal May 1 and then on May 22 The letter dated June 7 has been penned by Dr Palitha Mahipa- "The positivity rate is high, the surveillance system is weak, la, WHO Country Head for Pakistan, and states that the coro- there is limited capacity to provide for critical patients and the navirus has spread to almost all districts in the country, with population is not ready to adapt to change in behavior," the major cities making up a majority of national cases. letter stated, adding that Pakistan's reproductive number (R), "Government intervention on April 12 detailing social distanc- which is an estimate for the number of individuals infected by ing measures, including movement restrictions, closure of each carrier, is also greater than 1. schools and businesses, international travel restrictions, and The WHO recommended that strategic decisions should be geographical area restrictions were instituted with the aim of taken to either tighten or loosen public health measures. limiting the spread of the disease." "These difficult decisions will require the need to balance the However, the partial relaxation of restrictions on May 1, fol- response directly to Covid-19 which includes intermittent lock- lowed by a complete relaxation on May 22, has caused the downs of targeted areas." Stressing the need for ramping up rate of infection to increase, the letter noted.. testing capacity beyond 50,000 tests per day and strengthen- According to WHO recommendations, any government that ing public health measures, the WHO recommended that the wishes to lift lockdown restrictions must meet a set of condi- government enforce a "two weeks on, two weeks off strategy" tions. The letter noted that so far, Pakistan has not met any of as it offers the smallest infection curve. the conditions which include: Pakistan's coronavirus cases surpassed the 100,000 mark last  Disease transmission is under control week. As of June 9, more than 110,000 Covid-19 cases and  Health systems can "detect, test, isolate and treat every 2,000 deaths have been reported. case and trace every contact" (Imran Gabol, Dawn 9 June )  Hot spot risks are minimized in vulnerable places Covid-19 and importance of Pakistan health data worrisome data timeliness as compared to neighboring states

As the Covid-19 pandemic contin- overall societal welfare. While life expectancy is the cy in Pakistan is the lowest ues to cause havoc across different Health data collection lowest in Pakistan as com- in Pakistan i.e. 67.1 years parts of the world, we all have How the data is collected and pared to other countries of as compared to 69.4 years made public for the rest of the been keenly following the data that the region, the cumulative in India, 72.3 years in Bang- world? Timely Covid-19 data is health expenditures by ladesh, 76.8 years in Sri is updated on a daily basis, key produced by health workers, who federal and provincial gov- Lanka and 76.7 years in statistics gathered around the submit diagnostic reports to local ernments in the Financial China. Infant mortality rate world, the number of confirmed health departments. Year 2019 increased to (IMR) is 57.2 per 1,000 live cases, deaths and recoveries. The health departments record the cases in an administrative data- Rs421.8 billion from births in Pakistan, as com- This open data has been immense- base. The relevant ministry pub- Rs416.5bn of previous year, pared to 29.9 in India, 25.1 ly useful for researchers who have lishes the data daily from the data- showing a growth of only in Bangladesh, only 6.4 in come up with policy relevant evi- base and international bodies such dence of the effect of various 1.3 per cent. Moreover, the Sri Lanka and 7.4 in China. as the World Health Organisation measures for abating the disas- allocation in health sector However, in maternal mor- gather and aggregate these figures trous impact of the pandemic. was 1.1pc of the Gross Do- tality rate (MMR) Pakistan across countries. A key source in this regard has mestic Product (GDP). Ac- has better number as com- This has also been implemented in been the Johns Hopkins Corona- the case of Pakistan with the crea- cording to Economic Survey pared to India and Bangla- virus Resource Centre, which pro- tion of government of Pakistan’s 2019-20, the national desh. The MMR per vides a comprehensive world view health advisory platform, which is a health security is increas- 100,000 deliveries is 140 in of how the pandemic has unfolded good initiative in tabulating key ingly threatened in Pakistan Pakistan, as compared to with real-time data throughout the statistics on the pandemic in the due to population growth, 145 in India and 173 in day. This article looks into how the country as well as at the province timeliness of data collection and rising urbanisation, envi- Bangladesh. In Sri Lanka level. The key is to act on it in a sharing is key and how if it were to ronmental pollution and MMR is 36 and in China timely manner to avert any major be applied for other national eco- change in lifestyle of peo- only 29 in 100,000 live disaster. nomic and social variables, could ple, among other factors. births. prove to be a critical resource in Cont.. on p. 9 It shows that life expectan- (Dawn, 12 June) making policies that could improve

7 A fortnightly report on Health (1-15 June, 16-30 June) NEWS DIGEST There’s something wrong or really good with coronavirus strain in Pakistan’ Leading health experts wonder if there’s and start research on the nature and behavior something wrong or something really good in of the coronavirus in Pakistan. Pakistan concerning the spread of the novel Another renowned health expert, Dr Saqib coronavirus — officially, the Severe Acute Ansari, said why the number of deaths was Respiratory Syndrome-Coronavirus-2 (SARS- less in Pakistan as compared to the rest of the CoV-2) — that is behind the global pandemic, world was a million-dollar question. which appears to be less aggressive and trans- He called for initiating research to ascertain missible in local population, as is evident from that if “the virus has lost its aggressiveness in a comparatively low mortality rate and fewer Pakistan” and why it appeared to be lesser number of cases than expected in the country. infectious and lethal for Pakistani people. Despite reporting its first case of COVID-19 on “What current data suggests is that instead of February 26 and first death from the virus in multiplying, an add-on effect of coronavirus is the second week of March this year, Pakistan being observed in our society. Secondly, it has so far reported 1,483 deaths and around appears that its secondary and tertiary infec- 67,000 cases of COVID-19 from the entire tions are comparatively less lethal as com- also believes that there is a possibility that the country of 220 million, despite implementing a pared to other parts of the world, especially in strain of coronavirus prevalent in Pakistan highly-ineffective lockdown in the initial days the US and the UK,” Dr Ansari said but added might be different from the rest of the world, which has largely been eased for last two that “it does not mean that people should while Pakistani population’s immunity might weeks. abandon all the precautionary measures as it be different from the West seeing the diverse “I don’t agree with the hypothesis that we is still resulting in 70 to 80 deaths in the coun- genetic makeup. have stronger immunity as compared to the try daily”. “There may be some environmental factors in rest of the world due to frequent vaccinations He said as far as the immune system of Paki- our region due to which the virus appears to and having some special immunity,” said Prof stani population was concerned, they re- be less virulent here but it could also be be- Saeed Akhtar, eminent transplant surgeon and mained exposed to a large number of patho- cause our reporting ability and testing capabil- a public health expert while talking to The gens throughout a year and their immune ities are a lot different than the rest of the News. “People of Pakistani origin, who born system remains active most of the time as it world,” Prof Mehr said, adding that it could and raised here, have higher mortality in the has to fight infections daily. also be a “wild guess as we still have not got United States and the United Kingdom as com- “When children of Pakistanis living abroad any concrete knowledge about the illness”. pared to the white people. There is a possibil- visit Pakistan, they get sick by eating food and “The only thing that we know about COVID-19 ity that we have a different or less virulent drinking water here but our children and peo- this far is that we don’t know much about the strain of the virus. It may be possible that we ple remain healthy. This is because we are disease and the virus,” Prof. Mehr said. have a less deadly strain of the virus as com- exposed to pathogens a lot more as compared ‘ pared to the US and Europe.” to people in the Western world,” he added. But a leading virologist and molecular scien- Prof Akhtar, who is also a trained and qualified “We have seen instances where people infect- tist, Prof Saeed Khan, from the Dow University epidemiologist with a degree in public health ed with coronavirus met with dozens of other of Health Sciences (DUHS), believes that there from the Yale University, USA, said there was a people but when they were tested, they were is no change in the coronavirus as it is 99 per need to research the structure and virulence negative. This is not the case in countries from cent the same virus which originated from of the coronavirus and environmental factors where we have acquired the virus. Corona- Wuhan, China. He said gene of this virus had that contribute to the spread or limit the in- virus is a lot more aggressive and lethal in around 30,000 nucleotides and only 11 of fection. He, however, deplored that the meth- countries from where we have acquired it. them had been found different than the origi- od of data collection of COVID-19 cases and There is something wrong or really good in the nal virus that originated from China. reporting of deaths in Pakistan was “not scien- strain of coronavirus we have in our country, “Viruses do not change their virulence in few tific at all”. which needs to be looked into,” Dr Ansari years and it takes decades for a virus to be- “I don’t agree that we only have 67,000 cases added. come less or more virulent. COVID-19 trans- in our population. This is not possible at all. I “There is some qualitative or quantitative mission and mortality due to this virus are challenge them, if they conduct 100,000 tests change in the transmission of coronavirus in indeed less but it depends on the environmen- a day, there would be 10,000 to 15,000 posi- Pakistan. It appears that when this virus is tal and genetic factors also. There is a need to tive cases from our population. There is an transmitted from the primary source to other conduct thorough studies on it,” Prof Khan immediate need to enhance our testing capa- persons, the viral load remains less or it does said but added that at the moment, all the bilities and improve data collection to take not multiply as rapidly as in people of other leading researches in the country were busy in appropriate measures,” Prof Akhtar said, countries or races in the world. Secondly, firefighting and testing instead of research. warning that exponential growth in a number there may be some mutation in the strain of “Scientists at all the labs, including ours at the of cases and deaths was expected in the coun- coronavirus in our country but all these possi- DUHS and those at the Karachi University and try from mid of June. bilities need to be thoroughly looked into and in Lahore and Islamabad, are busy in testing “What we have done with our people during researched in the labs,” Dr Ansari said and COVID-19 instead of doing any research. There Eid days is devastating after we lifted all re- urged authorities to invest in virologists, pub- is a need to conduct research which would strictions and allowed people to mingle for lic health experts and scientists instead of benefit us more than utilising scientists for three to four days. Its outcome is expected wasting money on buildings and purchasing testing samples 24 hours a day,” Prof Khan within the next two to four weeks in Pakistan. equipment. added. I fear an exponential growth in deaths due to Another health specialist, Prof Muhammad (M. Waqar Bhatti, The News, 1 June ) COVID-19 by the mid or end of June,” Prof Tariq Mehr, the incharge of COVID-19 treat- Akhtar warned but added that authorities ment ward at the Hayatabad Medical Complex should improve their system of data collection Peshawar and expert of anti-viral medicines,

8 A fortnightly report on Health (1-15 June, 16-30 June) NEWS DIGEST 100 fatalities From p. 7 From p.10 Data timeliness and Pakistan The research concluded that a high fatal- If data on Covid-19 is available timely, Trend of CFR (%) of COVID-19 in Paki- ity among elderly population and its why not extend this to development da- stan association with co-morbidities gives us ta? In general, developing countries in- 60 years and above presented with a a chance to taper our intervention. cluding Pakistan face severe delays in rapidly progressing disease along with Standard Operating Procedures for quar- making the data available at the right fever, sore throat and cough as present- antine and isolation of elderly should be time. ed in other countries. Patients above 60 revised. Keeping our traditions and cul- A recent World Bank data blog has ana- years are dependent group of our socie- tural norms regarding respect and care lyzed that among low-income countries, ty so are less than 12 years and usually of elderly, home quarantine measures less than 40% have data on poverty since have little community exposure as com- should be robust in big cities like Kara- 2015, almost three in 10 have not taken a pared to rest of the population. Since chi. Male population is more prone link- population census in the past 10 years, results showed no death reported below ing their social activities in a male domi- and only 9% have monthly or quarterly 20 years age group, high CFR among 60+ nant society. Analysis of first 100 COVID- production indices to track current eco- patients is relatable to their low immuni- 19 related deaths is a cue to assess the nomic activity. ty and co-morbidities. Our results outcome of measures taken so far. All This makes the fight against economic showed very short span of illness and provinces should take all necessary and social problems increasingly chal- even shorter duration of hospitalization measures to protect their vulnerable lenging. Similar is the case for Pakistan, overtimes. Since the prevention population to lower the CFR further where the population census conducted measures were being observed all down. in 2017 after a passage of 19 years was acorns the country, access to hospital fraught with disputes and is still only par- and health seeking behavior of commu- tially available online on the Pakistan nity played a major role in cases regis- Bureau of Statistics’ website. Timely data tration. Comorbidities like Ischemic Excerpt from is crucial for governments to react quickly heart diseases, diabetes and hyperten- when a crisis occurs whether related to Chaudhry1, , A., Ikram, A., Baig, M. A., Sal- sion seems to play a critical role in dis- environment, health, finances or conflict. man, M., Ghafoor, T., Hussain, Z., . . . Akram, ease progressions as determined by With respect to the current pandemic, K. (2020, June 9). Mortality Analysis of COVID- some other authors Highest CFR was data timeliness has enabled countries to 19 Confirmed Cases in Pakistan. Retrieved observed in KP province (4.39%) fol- compare the possible trajectories that from https://www.medrxiv.org: https:// lowed by Sindh province (2.31%). Kara- they are likely to face and scale the ap- www.medrxiv.org/cotet/10.1101/2020.06. chi city, the most populous metropolitan propriate measures taken to fight the 07.20121939v1.full.pdf and hence most affected by epidemic in disease accordingly. Sindh province, observed early preven- In Pakistan’s case, the pandemic also ex- tive measures as compared to rest of posed the weaknesses in terms of data country. There is direct association be- collection in the present system when tween social distancing and disease countrywide lockdowns necessitated the transmission rate. Hence a rise in CFR in need for cash transfers to the most vul- KP and low in GB are directly relatable to nerable groups. their social distancing policies. The pandemic necessitated data collec- tion and registration at the household level for taking appropriate measures such as distributing ration bags to the needy. To get to a world with timely develop- ment data and to implement evidence- based policy responses, countries must invest in statistical capacity and national data systems. The current pandemic should be taken as an opportunity to build the much-needed capacity that most developing countries lack to effec- tively deal with any crisis in the future. The writer is a doctoral candidate at the Bartlett, UCL (Tehreem Husain ,The Express Tribune, 15 June )

9 A fortnightly report on Health (1-15 June, 16-30 June) RESEARCH REPORT The first 100 fatalities

National Institute of Health, Pakistan and .Field Epidemiology and Laboratory Training Program, Pakistan, researchers conducted a research “Mortality Analysis of COVID-19 Confirmed Cases in Pakistan”. They conducted a descriptive epidemiologi- cal analysis of first 100 deaths reported among RT-PCR confirmed COVID-19 cases. Demographic, epidemiological and risk fac- tors information was obtained associated comorbidities and clinical signs and symp- toms were recorded and frequencies were determined. In December 2019, several cases of pneu- monia of unknown causes were reported from Hubei, China later named as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The international Committee on Taxonomy of Viruses renamed the virus as acute respiratory syndrome coronoavirus -2 (SARS-CoV-2). The World Health Organi- zation (WHO) announced the epidemic caused by SARS-CoV-2 as coronavirus dis- ease 2019 (COVID-19). In subsequent days, asymptomatic people lead to the outcome ities and mortalities was pertinent for time- world has seen a rapid spread across inter- of global spread as well as an underestimat- ly and robust public health responses. Our national borders and high rates of morbidi- ed mortality rate. Morbidity and mortality objective was to investigate the characteris- ty and mortality. in developed countries has been document- tics of Patients died of novel corona dis- Considerable efforts has been made to un- ed high, attributed to having big proportion ease, their spatial and temporal distribution derstand the mechanism of disease arose of aging population as compared to chi- and risk factors associated with them. as severe respiratory disease with 89.1% na .we know that virus is affecting badly the During the early phase of outbreak, report- nucleotide similarity to a group of SARS-like extreme ages and those with co- ed cases were mostly travelers from other coronavirus found in bats in China Many morbidities. (10). countries, mainly Iran. Testing for COVID-19 developed countries with strong health Analysis of fatal cases in China has shown was done for symptomatic as well as infrastructure are facing high mortality hit. high rates in patients with co-morbidities of asymptomatic people who had an interna- Case Fatality estimation has suggested a Ischemic Heart Diseases, Hypertension, and tional travel history. First death was report- range of 0.25%-3.0% with highest 3.5 in Diabetes. However, a higher risk in preg- ed on 18th March with gradual increase in China alone at its earliest However, a cor- nant women has not been established so CFR to 1.67% till first 100 deaths were ob- rect estimation of the disease is still needed far Literature shows a death rate among served, which is well below the level esti- as the situation is changing rapidly. Some hospitalized individuals was 15% with mean mated by some researchers. Initial phase of researcher suggested an unadjusted range period of 14days from onset of symptoms epidemic shows more cases having interna- of 4.4% to 4.8% considering rest an under- to deaths of patients. Since first confirmed tional travel history which later on lead to estimation (5) case reported on 26th Feb and first death local transmission. Early quarantine of trav- . Initial estimates among Novel Corona In- reported on 12th March, 2020, number of ellers, prompt adoption of social distancing fected Pneumonia (NCIP) suggested a hu- cases are increasing exponentially and so is as well as national level lockdown policies man to human spread in symptomatic as the case fatality rates. In the light of rapidly might have played their roles in deceler- well as asymptomatic No significant differ- changing epidemic situation, a rapid and ating the epidemic curve. Our results ence in viral load of symptomatic and ongoing epidemiological analysis of morbid- showed that age above 60 years is the most vulnerable age group as depicted in other studies. Children and young age groups are seem to be protected while middle age group having highest community exposure are mildly affected. An increased CFR has been observed with increasing age. Cases presented with a range of signs and symp- toms. Fever, cough and breath shortness are the most reported signs and symptoms. However, severe acute respiratory syn- drome seems the hall mark of mortality.

Cont... on p.9

10 A fortnightly report on Health (1-15 June, 16-30 June) SELECTED ESSAY Post-Covid pandemic By Zofeen T. Ebrahim The Covid-19 pandemic may have spared many women from directly getting infected, but in many ways it has exacerbated the impact on their sexual and reproductive health. Giving birth already comes with its own set of risks but during the Covid-19 pandemic the delivery process is complicated manifold. Many have to face a difficult decision — whether to give birth in a hospital setting or opt for a home birth. The former comes with the risk of infection, the latter may mean limited equipment if When the government announced a ment (PPE). Because of the risk they are the delivery turns into a medical emer- lockdown in April, FP services were the exposed to, they should also be provided gency — bleeding after giving birth is first casualty and women were unable to incentives to encourage them to contin- one of the leading causes of maternal get either supplies, or antenatal or deliv- ue their services. deaths in Pakistan. ery care. This was particularly true for No doubt, over the years, LHWs have The United Nations Population Fund rural women relying on government fa- been burdened with many tasks that looked at three sexual and reproductive cilities. With a disruption in FP services, they had not signed up for initially, but health services affected by the pandemic it is not hard to imagine a spike in unex- given that they have built up trust and in 14 countries including Pakistan: births pected pregnancies, unsafe abortions, made inroads within the communities assisted by skilled healthcare providers, pregnancy-related complications and they work in, it may not be a bad idea to including midwives; births taking place in maternal deaths. use their services for mass awareness health facilities; and access to contracep- The country’s population, already in- about Covid-19. They can be trained to tion. All the countries surveyed have creasing at an annual rate of 2.3pc, will advise their clients on containment strat- high maternal mortality ratios — over double in less than 35 years to 440 mil- egies, explain what isolation and quaran- 100 deaths per 100,000 live births. lion by 2055! If FP services and supplies tine mean, and dispel myths and miscon- Is family planning on the government’s remain disrupted, the economic burden ceptions, while addressing stigma associ- radar? of a runaway population will increase. ated with the infection. Even if things were fairly good, there It is imperative that the government It is also a good time to set aside differ- would still be a 20 per cent decline in the consider the provision of women’s re- ences and for the federal and provincial use of the three key services, leading to productive health as an essential service governments to come together, partner a 17pc increase in the maternal mortali- and ensure the population welfare de- with the private sector and seek support ty ratio, or 25,493 additional deaths this partment’s FP centres are not only of donor organizations such as UNFPA, year alone. But if things were bad, it opened, but that they also have an ade- WHO and UNICEF in terms of technical would mean a 50pc decline in the use of quate number of service providers and assistance or to get uninterrupted sup- services, leading to 43pc increase in ma- supplies. plies of medicines, equipment and PPE ternal mortality, or 68,422 additional The country has a huge brigade of LHWs for healthcare providers. deaths. and community midwives that are the If this pandemic has taught us one thing Experts agree the pandemic may lead to main providers of FP information and it is to think out of the box. There is huge a significant increase in maternal deaths modern contraceptives. But they seem potential in digital technology. This may mainly due to reduced access to contra- reluctant to make house visits for fear of be an opportune time to train healthcare ceptive services. Already the use of con- getting infected by the coronavirus. The providers in telemedicine. Already quite traceptives by Pakistani couples is low as fear is not unfounded. The government a few women doctors have returned to is the discontinuation rate. must find innovative ways and train work using the telehealth platform and About 45pc of women in Pakistan who them to carry out their work in the pre- this may open up a new world for scores use any of the modern methods of fami- sent circumstances. For instance, instead of others like them. ly planning (FP), get their supplies from a of entering homes, interactions can be The writer is a freelance journalist based government health or an FP facility. A conducted at the doorstep. in Karachi. sizable proportion, particularly those in But before that, these front-line work- Published in Dawn, June 24th, 2020 urban/semi-urban areas, get their sup- ers, some of whom will be providing plies from NGO-run clinics, Lady Health antenatal and post-natal care as well as Workers (LHWs) or directly from phar- delivery services, need to be equipped macies (condoms and oral pills). with proper personal protective equip-

11 Institute of Historical and Social Research (IHSR)

Institute of Historical and Social Research (IHSR) is a Karachi (Pakistan) based research organization with a very vibrant progressive and pro-people vision. Established by the S.M. Sohail Trust, the Institute is an independent and non-profit organization which undertakes researches on historical and socio-political issues, particularly with reference to Pakistan. The researches conducted by the Institute cover different disciplines independently as well as in a multidisciplinary manner. In the area of historical research it deviates from tradi- tional modes of historiography and views history from below, encompassing the common people, adopting their sociopolitical contribu- tion, ethos and values and creative pursuits as the major determinants of historical evolution. The Institute, on the one hand preserves the sources of peoples’ history, retrieves the relevant historical documents, and conducts original research, dealing with the ways of life and thinking and the movements reflecting the concerns of the people at a given point in the past. On the other hand, the Institute disseminates its historical research in the form of books, monographs and reports on occasionally held seminars and conferences. Preservation and publication of the political literature of Pakistan is of special interest for the Institute.

In the domain of social research, the Institute focuses on contemporary socio-political issues of the country, again with the common people as the central point of reference. These researches are done and projected in a manner that these can be made use of by the policymakers, planners and civil society representatives. These researches generate, through access to the relevant official and un-official primary sources, interaction with the informed individuals and technical experts, consultation with opinion-makers, and amassing information through field work. Such researches of the Institute find place in its publications, policy briefings, seminars, and in the press conferences and are made available at the Institute’s website.

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