After Pakistan joined the countries with coronavirus deaths, it is becoming increasingly clear that self-isolation and distancing is the only way to keep the virus at bay.

"Your healthcare system is not equipped to support you," pronounced overworked and sleep-deprived Dr Shobha Luxmi, an infectious diseases specialist at Dow University of Health Sciences, Karachi (DUHS).

"And if the system does not support its own staff, do you think it will support you?" she asked and then in the same breath added: "Take charge of your health; stay at home and keep your children at home!"

But then Pakistan's healthcare system was never designed, even on paper, for emergency response preparedness. "Our hospitals are not planned for it, people are not trained, isolation facilities are not there and there is no contingency plan. The system is as old as 1947 and we never thought to revise or improve it," Dr Luxmi said, not mincing any words.

The private hospitals are no better, she said. "Those are merely commercial organisations."

"We are not prepared for this type of public health emergency and we will never be prepared if our health expenditure remains static at 3%," points out Dr Ahsan Jamil, deputy general manager, clinical affairs, medical directorate at The Indus Health Network.

"The ground realities clearly indicate that our capacities are restricted and something on a war footing is needed as a desperate measure," he adds.

A drop in the ocean

For now and according to a recent report from NDMA, across the country there are 15 testing facilities, a total of 8,718 beds available in quarantine, 2,058 beds in isolation, and 35 designated COVID-19 tertiary care hospitals. For a country of 200 million, this is a drop in the ocean.

Coupled with a dismal healthcare system infrastructure, the social indicators also do not favour addressing COVID-19 easily, points out Dr Jamil. He says issues of "funds disbursement, lack of availability of testing kits, but above all, a dearth of human resource in the health system" remain huge barriers. He gave the example of the government’s performance related to "containment and isolation of pilgrims at the Taftan border" terming it "sub-optimal".

A complete lack of "background knowledge" and "investigation expertise" coupled with "absolutely no passion" to serve makes the situation all the more depressing for Dr Luxmi.

At a training she carried out just a few days back, of 52 doctors from the Sindh government, whom she asked if they were willing to serve the public, not a single person raised his/her hand, she said. "And they had sent all the junior doctors when the world over, the lead is being taken by seniors."

She suspects the seniors from her fraternity will not go near a potentially sick patient out of fear of getting infected.

The system is burdened

With over 400 people visiting the lungs diseases ward at the DUHS handled by just a dozen or so staff, to get screened and tested, she says there is complete chaos.

"If we refuse, based on their history, they turn around and get angry and some even get downright abusive," says Dr Luxmi. "People are counseled but they don't maintain social distancing," she adds.

In addition, companies and offices — local, multinationals, offices, government offices — are sending their staff to get a clean chit so they may be permitted to come to work. "Why burden the hospital for that; instead they should just close their offices and ask the staff to work from home," says an irate Dr Luxmi.

She says results of the tests take between six to seven hours and they are able to carry out tests for between 30-40 people. Of these, they are usually getting three to four positive cases daily.

The government with help from the World Health Organisation has procured testing kits from the US, UK and Korea. "Just because these tests are free for the people, they tell us we cannot refuse them. We have 1,200 kits right now and each test is costing the government somewhere between Rs8,000 to Rs9,000," says the DUHS doctor. "People need to act more responsibly as these kits are also in limited supply and must be saved for those whom health practitioners think need to be essentially tested."

Other screening centres in Karachi are established at The Indus Hospital, the Jinnah Postgraduate Medical Centre (JPMC), Dr Ruth K M Pfau Civil Hospital, and the Aga Khan University Hospital.

Not enough microbiologists to screen the population of Sindh

Sindh government's spokesperson, Murtaza Wahab, says availability of kits was not an issue nor was there a dearth of resources. "And even if we get more, we need to understand that we have limited testing capacity. There are just not enough microbiologists to screen an entire population of Sindh," he says. That is why, he says, people should show restraint and help stem it by staying home.

Wahab also said that if people cooperate in this time of adversity, and not panic and head straight for health facilities, many issues can be overcome. Giving an example of a family's cooperation, he said: "A family of six tested positive and they volunteered to go into isolation in their own home. There is police outside their home to ensure no one leaves or goes inside."

Isolation wards are set up to separate those infected from the general public and it is no picnic. "It's quite boring being in there and it's not that they are getting any special medicine that can only be given in the health facility," he says, adding that the same regimen can be applied at home and in more comfort.

Isolation or quarantine

This is supported by Dr Luxmi who says that with an already compromised healthcare system, people should seriously think of both home quarantine and home isolation and explains the difference.

Quarantine is done when coronavirus is suspected. The person may not have the disease but there is suspicion that he may be a carrier because he has recently travelled, has been in touch with a traveler, or has been in close contact with a coronavirus positive person. A person is in isolation when his tests results are confirmed positive

"If doctors send someone for home quarantine and isolation, the doctor must also ensure that the patient is well enough to take care of him/herself, or there is someone at home to take care of them," she says.

In addition, it can only work if there is a separate room and washroom for that person or all those (in that home who have tested positive).

"For those in isolation (which means they are definitely tested positive), the 14-day stay-at-home period does not mean they are out of danger for others but need to continue taking precautions. Each person gets tested every fifth day and only after their two samples (one each in 24 hours) come out negative can they step out of isolation. But sometimes it can take anywhere between three to four weeks till the results come negative. And if that happens the patient should continue to observe isolation.

"I understand that two weeks in isolation is not easy and it may cause a lot of anxiety to many people," says Dr Luxmi. "But there is no way out"

"Take care of your nerves, stay happy, take up reading, do some yoga or exercise, stay in touch with friends over your mobile, watch movies on TV, maybe even get some work done and attend meetings virtually or via video conferencing," she says.

"And quit smoking," she adds.

Dr Luxmi also emphasises that one should "use hand sanitisers or alcohol wipes and swabs to keep gadgets clean and wash one's own plates and cups and glasses with warm water and detergent. But if you cannot, whoever does it, should wear gloves".

Dr Luxmi's day does not end with seeing and screening patients. "The test results start coming in by 7:00 - 8:00 pm and I have to send the list of all the positive patients with their details to the Sindh government which then takes over from there."

She takes in queries from the government sometimes till 2:00 am and gets a few winks before getting back to work at 7:00 am. "If I slack, so will those working under me," she says.

Those who test negative are not informed. They can either call or come and get the reports from us anywhere between 24 to 48 hours and get counseling.

All tests are free of cost but the AKUH charges a registration fee as well as an admission fee if a patient gets admitted for treatment there. DUHS and the Civil Hospital treat the patients for free.

Dr Luxmi, for now, is satisfied with the two isolation wards set up at the DUHS. "Each room can accommodate up to nine patients. There is a clean washroom and minimal furniture and healthcare providers wear specialised gear to protect themselves from getting infected."

But under the circumstances and with all the inadequacies, she says the Sindh government was doing "a good job".

The same was endorsed by Dr Jamil. "I think Chief Minister Sindh's energy is infectious and uplifting in these depressing times," he says, adding that in times such as these, "mutual cooperation, collaboration and coordination paves the way and dire emergencies are controlled with team work".

With more pilgrims returning and over 2,700 quarantined in Taftan (with over 700 to be moved to Sukkur), over 700 at Dera Ghazi Khan, 300 plus in Sukkur and Gilgit Baltistan each, and over 130 tested positive, the game is far from over. And that is where media comes in, says Dr Jamil. "Media should review and monitor the situation and without creating panic must highlight the gaps and deficiencies in the implementation process," he says.