Interview with Dr. Shimail Daud, CEO, Maryam Memorial Hospital: 'Shortage of specially-trained ICU physicians is a bigger issue than shortage of ventilators'

With a background of being a physician, Dr. Shimail Daud is a prominent name in healthcare management in Pakistan. He is the CEO of Maryam Memorial Hospital, which has two facilities in Rawalpindi and Islamabad providing a range of clinical, diagnostic and patient services. A leading voice on economic and policy issues, Dr. Shimail has previously served as the President of Rawalpindi Chamber of Commerce and Industry (2013-14) and also remained a member Federal Board of Investment. Currently, he serves as a member Board of Trustees at the PRIME think-tank in Islamabad.

As the COVID-19 pandemic racks up cases in Pakistan, BR Research spoke to the healthcare professional to understand the country’s preparedness and the role private sector can play in easing the crisis. Selected excerpts are provided below:

BR Research: There is a continued lack of clarity over declaring a public health emergency in Pakistan. How do you see this situation?

Shimail Daud: What is evident is that the existing fault-lines between the workings of federation and the provinces have been laid bare by this crisis. For the past year and half, there was a certain narrative in the country about the 18^th Amendment and about provinces not doing enough. There was also bickering at the political level. Now in this emergency, that situation has aggravated and there is very limited working relationship between the federating units.

Within this context, what was required was to overcome old feuds and to have political harmony. But the federation is still lingering with old differences of opinions when everyone else has been advising to shed the ego in the times of a global emergency. The result is that there is no national unity and there have been delays in decision making. Eventually, the NDMA had to move in with support from the Army.

BRR: As we speak, the number of cases has already crossed the 1,000 mark. What does the trend line tell you as to where we will land eventually?

SD: The figures that we have from the government are the figures of only those patients that are “tested” positive for COVID-19. These figures are not fully transparent and they are not realistic. On transparency, why is it that new COVID-19 cases are being uploaded after waiting for 24 hours instead of doing this activity in real time? And as for realistic picture, we know that according to many experts, the number of reported positive infections is about 14 to 15 percent of the overall infection, which means that the rest of the cases are undetected and therefore spreading through the population.

The ground reality is that number of infections is potentially large. Now NDMA has created a number of quarantine centers. But the way things are being handled shows a lack of coordination. On top of that, the private healthcare sector is totally operating in a vacuum as the public sector is not talking to it. There is no clear defined policy on how to deal with this crisis, there is no political harmony, and to top it all the reported data is non-transparent in nature. Unfortunately this state of affairs will not help us gain control over the deteriorating situation.

BRR: Based on what you have read and know through practice, what is your estimate on hospitalization rates and fatality rates in Pakistan from this crisis?

SD: If the positive, “known” cases are 15 percent of the total, the “suspect” cases are 85 percent, which is a high number because there is not much testing done at this stage. One can see that the daily positive cases in Pakistan are growing at a rate above 10 percent. We need to slow this rate down. Our growth rate is still 1X, or close to similar growth rates as Italy or Spain. The recent international experience is that once you do a complete shutdown, the cases go on increasing because there are some cases in the pipeline and eventually after reaching a certain peak, there will be a plateau.

We are hoping that the growth rate comes down and the cases plateau. So far the only good news is that in our case fatality rate (CFR) is less than 1 percent, and I hope that the CFR stays below 1 percent so that we do not see as many critical patients. That’s the only safety in numbers that we can get. God forbid if we see a similar outburst of patients as we have seen in Europe, we will not be able to survive the similar impact because our numbers will be far bigger due to the fact that our healthcare system is completely exposed and shallow.

BRR: Then what could be the best possible way to curtail the spread of this disease?

SD: The government needs to somehow gain the trust of patients who have symptoms, so that such patients can be diagnosed, isolated, and their contacts are quickly traced. But it sends a wrong message when high-profile COVID-19 cases are allowed to self-quarantine at home and cases from low-income localities are nabbed and taken to hidden quarantine center somewhere and put away. The storyline that patients are dying in these centers hungry for air will keep a lot of people from reporting the symptoms.

We need to come out at the national and provincial level with a clear message: if you are diagnosed with COVID-19 and if you can guarantee, depending on your status, to quarantine yourself at home, provided your symptoms are at a low-risk level and there is no difficulty breathing, then you can do that; and if your symptoms progress, you will have to be hospitalized under care. There is a set pattern of symptoms and diagnosis and progression on the basis of which i) you could stay at home or ii) you could be hospitalized in a mass quarantine place, or iii) you are admitted to a closely-monitored space, or iv) you are intubated, nebulized and ventilated at the critical stage.

This is the sort of communication that is non-existent because there is no leader at the top. There are multiple people in charge who are not talking to each other. That is why our response to fight this disease will be confused and all over the place. Things will settle down only if God willing our stars go right.

BRR: Given the state of public healthcare infrastructure, how are private sector hospitals thinking to manage this challenge?

SD: At this stage, I think that the private sector cannot convert its facilities into quarantine centers, it cannot create isolation rooms, and it cannot suddenly provide critical care expertise. But what it can do is ensure that their hospitals continue serving the normal population for their normal medical needs. Encouraging the private sector to keep their doors open for patients is very important. In the region that I operate, some hospitals have completely closed their doors for ordinary patients, and that is very unfair to the people in these times.

Private sector can also play a role in early identification of the disease. We can run fever outpatient clinics, so that the disease is identified earlier on. We already know that 70 to 80 percent of patients in Pakistan go to private service providers for their healthcare needs. Therefore, it is logical to assume that in these times patients will be more comfortable going to a private service provider to see if they do need help regarding COVID-19. One of the most neglected aspects in our crisis management is to use existing facilities.

In order to diagnose a patient for COVID-19, a combination of patient history and simple lab diagnostics – such as blood tests, chest x-ray, and liver function test – can be really helpful in evaluating if a patient is really progressing towards COVID-19 or already has COVID-19. Then the next step could be to go towards the PCR tests, which are already limited. These are the basic diagnostics that are available in most of the laboratories in most of the private hospitals. Even smaller hospitals or secondary-care facilities can play a critical role by being the eyes and ears for filtering the right people towards quarantine centers or designated treatment facilities.

BRR: How challenging will it be for general service hospitals to isolate between regular patients and coronavirus patients?

SD: What the government does not understand is that they cannot shut down all outpatient departments (OPDs) of all hospitals. I run two private hospitals and I haven’t shut down my OPDs. We have a reduced number of doctors who are available, but we are open. We are taking in patients, but we are following a completely simple regimen where we ask patients certain questions about their contact history and symptoms and we either have a suspect patient or a non-suspect patient. We only treat the non-suspect patient. If we have the suspect patient, we might give them the initial diagnosis, act as a fever clinic, and then we direct them towards a government facility.

Now what the government is doing is that instead of creating separate space for treating active COVID-19 patients, they are converting existing hospitals into COVID-19 hospitals. That is fine, but the government has to answer where other patients should go when they have cardiac events or acute appendicitis or patients who are in the middle of pregnancy. The authorities need to realize that people in Pakistan will still get sick with diseases other than COVID-19 and that they will need help. How will the normal patients cope during these times?

BRR: In the end, the mass survival of critical COVID-19 patients seems linked with the availability of ventilators. How do things look on this front?

SD: The known figure of available ventilators as of March 28 is between 1500 to 2000 ventilators. But over the last two days, the update is that the government has ramped up the capacity to 19,600 ICU beds, and such ICU beds have to have ventilator capacity as it is the ultimate requirement. I feel that they might not have the said amount of ventilators. We do know that young engineers have used 3-D printing technology to create multiple-use ventilators. That could be one ray of hope. We also heard that 800 ventilators were to come from China.

At this point, the known quantity of ventilators is about 2,000. But the larger issue is the availability of critical-care specialists and pulmonologists and anesthetists who can operate such equipment. The shortage of specially-trained ICU physicians is a bigger issue than shortage of ventilators. We might not have the specialists and the critical staff to support the increase in ventilators. We are hoping that the number of critical patients does not increase. But it looks like we might start seeing more critical patients.

BRR: Is there truth in news that there are some ventilators that are non-invasive and which can be used at home by lay people to care for the elderly?

SD: When somebody needs ventilation, their oxygen saturation will be low, below a reading of 92, whereas the normal breathing environment at room temperature is at a reading of 98 or above. When somebody needs ventilation, they can be put on a non-invasive ventilator, but it has to be in a hospital setting. It will be difficult for people at home to understand the level of complexity that is required in operating such machines. Some people do take CPAP/BPAP ventilators when they suffer from sleep apnea. But COVID-19 is a situation where lining of the lungs is totally blocked with mucus and not enough oxygen is going in and out. Such patients might require other symptomatic IV-support in a hospital setting.

BRR: There is a reported shortfall of testing kits and protective gear for healthcare workers. Can such equipment be locally produced?

SD: Some of the things can be done right away. But there is not enough understanding, as some people are saying Sialkot can make ventilators. Yes they can, but in these times they would have to get the design, they will have to make the equipment, then test it, get it certified, and all of that takes a long time. But still, we should continue the effort to make our own monitoring equipment and ventilating machines.

In the short term, people can make masks and hand sanitizers, but that is at a basic level for protection. People are now trying to make medical gowns and protective gears for doctors. National-level textile manufacturers have the machines and they can make slight modifications to produce such stuff.

The government needs to talk to the big movers and shakers in the private sector to get this sort of activity going. Look at UK, where Dyson has started making ventilators, because it has the capacity and the tools to do it. Here in Pakistan, we need to do more policy-level things and create a feedback-loop between the public and private sectors to get these activities going.

BRR: You may have noticed that there is a sudden rise of telemedicine, and with it, the risk of fake doctors and quacks. What can be done immediately to safely deploy this segment?

SD: We have a tele-medicine startup and we have reached out to the federal and provincial governments to help out remote patients who are getting up in the morning worried if they have caught the virus. But so far we have not heard from the government people at any level. This is the level of seriousness of the people who are supposedly in charge.

Some people on their own are coming up with telemedicine solutions, but they are very small-scale in nature. Either they are chat bots, or they are in the form of FAQs, like the one on the government’s COVID-19 national website. Having said that, telemedicine is the way to go. If you go to the CDC USA website, their Tele Health service is the first line of choice. We need something similar in Pakistan.

BRR: In the end, are you aware of any organization that is doing research on corona-affected patients in Pakistan so that we can get a better sense of local spread?

SD: Not at all. There are global portals where molecular biologists are identifying and uploading the genomic structures of the SARS COV-II coronavirus from around the world. There is a list of countries that has done so. That cluster-based information is helpful because it can identify whether genomic structure of patients in say, Karachi, is different from patients in say, Rawalpindi. From that, we can also identify whether cases are related and that can help in contact tracing.

As per my knowledge thus far, data from Pakistan are not available on such portals as yet. What that possibly means is that we are not studying the blood samples of local patients, so we do not understand how the disease is progressing. And since we are not looking at this issue methodically and scientifically, we are almost blind. It’s almost like we have left these things to nature.