Can Pakistan's hospitals survive the pandemic?

Published on: June 12, 2020
Report by Haider Kaleem & Asra Haque

The country’s healthcare system is feeble and ill-equipped, and lags several years behind its counterparts in developed nations. With a global pandemic now in our midst, concerns abound whether Pakistan may suffer an even bigger human tragedy than other parts of the world due to the various weaknesses and shortcomings of its healthcare sector. So far, however, government sources claim that hospitals are adequately equipped, that health facilities are yet to experience any burden, claims that healthcare professionals vehemently deny. And as new cases emerge at a frightening pace, healthcare experts, authorities and COVID-19 response bodies have little recourse than to confess that the worst is yet to come.

Pakistan’s COVID-19 situation is very different from how the virus wreaked havoc in other countries such as Britain, France, Italy, Spain and the United States. It has come about as the 15th most infected country in the world, with a total of 125,9833 confirmed cases by June 12, 2020. But unlike the others, Pakistan has lost fewer lives compared to the rest of the world, with a somewhat encouraging recovery ratio of about 31.96% (at present Pakistan has recorded a COVID-19 mortality figure of 2,463, which is 1.96% of the national total).

These numbers may portray the situation as not too threatening. But the fact remains that in the past 24 hours alone Pakistan has recorded a staggering 6,397 new cases, and that healthcare experts and authorities have repeatedly warned the public that these numbers will spike at an exponential pace. It is apparent therefore that the pandemic is a ticking time-bomb. And our time might be up.

A Feeble Healthcare System

Pakistan’s healthcare system is incredibly deficient.

Even in regular times, the World Bank estimates, based on 2018 data, show that for every 1,000 Pakistanis, an average of 0.98 physicians and 0.67 nurses and midwives are available, while according to 2014 data only 0.6 hospitals beds are available.

When the COVID-19 outbreak began, it became apparent that the country’s already burdened healthcare system could not bear any more virus-positive patients.

Dr. Atif Majeed Chaudhry, Patron In-Chief of the Young Doctors Association in Punjab explains the situation. The YDA is among the various doctors bodies that have come into the limelight for their multiple protests against the lack of provisions of protective gear, medicines and other equipment to doctors not just on the frontline of the war against the pandemic, but who are performing their duties in non-virus related departments who have also taken ill with the contagion. The YDA are also among those collectives who had repeatedly, on live media, pleaded with the authorities to re-instate the lockdown to save the healthcare sector from impending collapse.

“If you observe the health sector even before COVID-19 you can see that multiple diseases have been continually present and we have always had overflowing hospitals and less beds and medicines,” he says. “Existing health facilities whether in the form of beds or ventilators were inadequate even before the pandemic. And now the contagion has hit Pakistan, and we are expected to respond to such a massive crisis, as well as the increased burden that comes with it. Is it difficult to see that the situation regarding lack of equipment and resources will become worse?”

Physicians per 1,000 people in Pakistan, for the period 1990-2018 – World Bank

Bafflingly enough, despite the time it was awarded, the Government of Pakistan barely moved to buffer its hospitals and health units with funding, facilities, and safety protocols. It was not until April that the Government initiated the construction of several field hospitals and assigned certain public hospitals as COVID-19 treatment and quarantine facilities.

Dr. Shahid Ali Chaudhry, an orthopedic and spine surgeon at the Jinnah Hospital who witnessed the number of infected patients wheeled in since the outbreak, understands the government’s initial lack of response as a misguided attempt to have the virus die out naturally by letting it propagate, and build herd immunity.

Hospital beds per 1,000 people in Pakistan, for the period 1990-2014 – World Bank

“Herd immunity rests on the fact that if 50-60% of the population becomes infected, the population begins to develop immunity to the virus,” he explains. “The government completely ignored the fact that the virus (SARS-CoV) has mutated around 10 to 11 times over the years and we see it returning in a different way (SARS-CoV2, or the novel coronavirus). How can you possibly imagine effectively attaining herd immunity against a virus that mutates at this rate?”

“Let’s say you develop herd immunity at this time. So if the virus mutates again, and your previous herd immunity is rendered useless, do you then move towards a new cycle of building herd immunity? It is not possible.”

As the contagion continued to spread unabated, speculative figures showed that the plan was actually causing the “curve” to shoot upwards rather than flatten itself out. The government scrambled to instate a complete lockdown in late March, without devising any SOPs or strategies to ensure that the healthcare sector could manage the pandemic. The lockdown saw a marked decrease in patients, however the government’s concerns over the country’s plunging economy rightly concerned healthcare professionals that the lockdown may be brought to an end far too soon, and previously manageable patient counts would turn catastrophic, far too many for Pakistan’s scant doctors with their scant supplies to possibly treat.

“If the government’s plan relied on exposing people to the virus to attain herd immunity then it was imperative that the healthcare system be provided all the required essentials to efficiently and safely manage and cope with this pandemic. There should have been a push towards immediate research work and building of infrastructure. But the government did nothing,” lamented Dr. Shahid.

As of May 30, 2020, 249 hospitals across the country are equipped with a little over 43,000 beds, of which 9,027 have been allocated to coronavirus patients. Of these, only 2,002 are occupied, indicating an occupancy ratio of 22.18%. In Punjab and Sindh, provinces that have recorded over 70,100 out of 93,983 confirmed cases, hospitals have yet to reach their coronavirus patient capacity. In Sindh, 201 of 1,214 beds in isolation wards are occupied, and in Punjab, 22,302 coronavirus patients have gone into isolation within their homes while 1,718 critical cases are undergoing treatment in various hospitals in the province.

Hospital bed occupancy by COVID-19 patients in Punjab

The low occupancy ratio may seem like an encouraging sign amidst a global health crisis, however, experts argue that the country is merely in the initial stages of the devastating effects the pandemic is set to wreak upon the country’s people and its fragile healthcare system.

Post-Lockdown Cases

In the past month alone, when lockdown restrictions were eased significantly across the country, the total number of infections nearly doubled, bringing Pakistan rapidly closer to the 100,000 infections mark. Dr. Atif on the other hand believes that official figures do not reflect reality due to Pakistan’s weak test sampling.

“Sampling has been far, far less than it should have been – there is no possible way we can ascertain the true picture of how many people have been and are currently infected with COVID-19. We as doctors believe that the actual number of infected patients is four times the figures shared by the government. If you have seen the report issued by the secretary of the Primary and Secondary Healthcare Department, he confessed that the number of infected is much higher than originally estimated and reflected in the data,” he said.

As the public continues to disregard protective protocols (whether due to ineffective COVID-19 awareness campaigns, lack of implementation of ‘smart lockdown’ SOPs by authorized bodies, or a general apathy to entire situation), healthcare workers have every reason to worry that the country’s healthcare system may well be on its way to a total collapse.

The rate at which new cases are emerging mean a greater influx of patients, perhaps far beyond what the country’s hospitals and health units are capable of handling. Already, beds have begun to run out at state-run and private hospitals. Of Lahore’s Jinnah Hospital, Dr. Shahid revealed that there were only 40 beds dedicated to COVID-19 patients, all of which were already occupied.

“Every single day I receive about ten calls begging me for a bed. Patients cannot even find beds in private hospitals, let alone public hospitals. Hardly 1% of Lahore’s populace can afford treatment in a private hospital, yet a lot of people are forced to approach private hospitals despite it being beyond their affordability because public hospitals are running beyond their capacity,” he said.

Meanwhile, about half the ventilators designated for virus patients across the country have already been occupied, but doctors do not believe a shortage of ventilators is the problem. According to President of the SAARC Medical Association as well as the Peshawar wing of the Pakistan Medical Association, doctors in Khyber Pakhtunkhwa have been unable to save a single virus patient that have had to be hooked up to ventilators. Once a patient becomes so critically ill that they are shifted to a ventilator, they might as well be already pronounced dead.

Doctors’ Side Of The Story

Dr. Atif asserts that the government’s claim that hospitals possess adequate facilities is a sham. There are no new beds, no new ventilators and no new equipment to help treat the abnormal influx of patients. COVID-19 cases are provided treatment with the same  facilities that were present in hospitals before the contagion spread to Pakistan, leading doctors to triage and divert precious resources away from the treatment of other patients with grave health concerns in many cases.

“This dearth of facilities has pushed us to take away doctors, beds and ventilators from other patients to help those infected by COVID-19. When these resources were scarce to begin with, how can we think they will be enough during a pandemic?” he questioned. “Hospitals are overflowing with patients and the healthcare facilities are abysmally inadequate.”

And that is not the only concern. Healthcare professionals themselves are contracting the virus at worrying rates, whittling down Pakistan’s already meagre force of doctors, nurses and other medical support staff. According to representatives of the Grand Health Alliance (GHA) and the Young Doctors Association (YDA), around 2,500 healthcare workers and professionals have been diagnosed positive, among whom over 20 have forgone their lives to the deadly virus. Most of these professionals were not even frontline personnel, directly tending to COVID-19 patients.

Local fears of being tested and carted away to isolation centers, and infrequent random tests by health authorities to detect hidden infections means that a frightening number of suspected COVID-19 patients have exposed no small number of doctors and nurses tending to non-coronavirus related medical concerns.

“The government declared that the barely 2% of healthcare workers who are treating COVID-19 patients directly should only get PPE, and decided that the remaining 98% of healthcare workers need no protective equipment,” Dr. Shahid alleged. “Current figures show 80% of infected healthcare workers never worked in COVID-19 wards.”

Dr. Atif also painted a dire picture of the healthcare sector’s many hurdles in the face of the pandemic. He alleged that protective kit supplies are erratic – they are available one day and then gone the next. And what PPE being supplied to hospitals are far below WHO-recognized standards.

Moreover, healthcare professionals on the frontline of the battle against the contagion, many of whom are young, fairly inexperienced doctors, have not been briefed on how to don and doff (wearing and removing) PPE due to confusing and non-standardized protocols issued by various authority bodies.

“These factors have contributed to increasing exposure and led to a rising number of infections in doctors. At this rate, in the coming 15-20 days we will see that the number of doctors dealing with other sick patients (not affected by COVID-19) exponentially decrease,” he said.

Facing The Facts

Sindh Health Minister, Dr. Azra Fazal Pechuho, in an impassioned speech in the Sindh Assembly on June 4, 2020, made her fears known that Sindh’s hospitals will soon run out of beds due to the dangerously high influx of COVID-19 cases ever since the lockdown had been lifted under order of the federal government.

“In order to fight the disease, we had to prepare ourselves and the health system, and go for a lockdown, but we did not do that,” she had lamented, voicing the concerns of doctors and nurses across the country who had taken to media time and again to beg the government to re-impose the lockdown.

The threat has managed to escalate to the point that the federal government has had little other recourse than to acknowledge and address the climbing concerns of the healthcare sector. Federal Minister for Health, Shibli Faraz, had warned that should the public continue to disregard SOPs, the government would be forced to reinstate restrictions. Currently, soft penalties are being doled out to those caught violating social distancing protocols, and refusing to wear masks and gloves in public – these penalties would increase in severity should people continue to flout protective measures.

But such a strategy is far too little far too late – plenty of damage has already been done. With reports of disturbingly widespread SOP violations during the month of Ramzan and Eid, the next few weeks will be incredibly painful for the healthcare sector and the dearth of emerging patients that will flood hospitals.