Interview with Dr. Zulfiqar A. Bhutta 'To fight Covid-19, focus more on epidemiology than just logistics'

Dr. Zulfiqar A. Bhutta is the Robert Harding Inaugural Chair in Global Child Health & Policy at the Centre for Global Child Health, Toronto, Professor of Epidemiology at the Dalla Lana School of Public Health, University of Toronto, and the Distinguished University Professor at the Aga Khan University and Founding Director of its newly-established Institute for Global Health & Development. Dr. Bhutta was the Founding Chair of the National Research Ethics Committee of the Government of Pakistan from 2003-2014 and a member of the UN Secretary General’s Independent Expert Review Group for monitoring global progress in maternal and child health MDGs (2011-2015). He currently heads the Medical & Allied disciplines panel of the Higher Education Commission. 

Dr. Bhutta is one of the most highly-cited academics in global health and has been ranked among the top one percent of Highly Cited Researchers globally. He is a recipient of the WHO Family Health award, the World Academy of Sciences award in Medical Sciences and a member of the National Academy of Sciences, USA. He leads large research groups based in Canada and Pakistan with a special interest in research synthesis, scaling up evidence-based interventions in community settings and implementation research in difficult circumstances and conflict settings.

BR Research recently reached out to Dr. Bhutta to develop a better understanding of the risks posed by SARS-COV-II coronavirus and the level of preparedness in Pakistan. Selected, edited excerpts from the online interview are provided below:

BR Research: There continues to be a considerable fog of uncertainty regarding the infectiousness of SARS-COV-II virus and the COVID-19 disease that it causes. For instance, it has been reported in the West that patients who have recovered from COVID-19 will be immune from getting sick again. But the question is: can such people still infect others as carriers if the virus attacks them again?

Dr. Zulfiqar A. Bhutta: I think these are early stages and there are many things about this infection that we don’t know yet. But it is a reasonable assumption that if you developed a mild or asymptomatic infection and recovered from it, your ability to fight this virus will be better than those who have not been exposed. Now, how long that immunity will last, is a big question. Whether it is for one season or more is something that will be known over time.

BRR: There are also varying reports over this coronavirus’s basic reproduction number (R-naught or R0). What kinds of data feed into R0 and how has it changed in Pakistan so far?

ZAB: An R0 is the virus’s ability to infect people, and SARS-COV-II is a highly-infectious coronavirus with an R0 of about 2.5. Just as the measles virus has an R0 of 12-18, it goes from one person to the other really fast. Other viruses like Ebola and Zika are highly infectious but only if you come into very close contact with the host.

The reality is that R0 of coronavirus, like other viruses, is influenced by a number of factors. One of them is population density. If you are living in a very remote area with hardly any people, then you wouldn’t expect the virus to permeate into that community, as opposed to a slum in a city. Other factors include the force of infection. So, there is debate around what the true R0 is. There are some who argue that the SARS-COV-II R0 in Pakistan is lower than 1, but there are others who believe that R0 is indeed 2+ because we haven’t tested many people and there may be silent transmission.

Here in Canada, the officials started modeling out with an R0 of 2+. And now, because social distancing has been very successful, the R0 in the most recent models has been reduced to 1.5. So, bottomline is that the R0 for SARS-COV-II is in that range, but it depends on certain factors such as how the population is behaving, how sparsely or densely an area is populated, and so on. There are exceptions that one person infected more than ten people, but the norm is that R0 is around 2, as it averages out overall exposures. At this point in Pakistan, there is no reason to suggest that R0 for SARS-COV-II is below 2.

BRR: Is there reason to believe that R0 in Pakistan may be affected by factors like the youth bulge, smoking incidence, hygiene prevalence, malnutrition, etc.?

ZAB: That’s a reasonable question. All those risks and counterfactuals are eventually balanced out in a model by some assumptions. We obviously don’t know 100 percent how this coronavirus will behave. We do know that in populations where there is smoking, infections have been higher. Same goes for air pollution as case fatality rates have been higher in areas where there is high particulate matter in the environment. But you have these competing risks that eventually balance out. Pakistan has a young population, but it is counterweighed by all the things you have listed, and many more such as overcrowding and co-morbidities in the relatively younger population and a less functional health system.

BRR: Pakistan’s case fatality rate is hovering around 2 percent, which isn’t as bad as Italy but worse given earlier expectations by some quarters that Pakistan was at low-risk due to its younger population. How do you see this situation?

ZAB: Comparing Pakistan with Italy is like comparing grapes with oranges. You cannot compare one country with the other without getting the “denominator” right. And the denominator is the number of tests conducted over time at population level, since case fatality rates are expressed per 100,000 of population. Italy does not have the best rate of testing in the world, but its testing is several folds higher than Pakistan.

When you look at case fatality rate, you can work that out on the basis of population or on the basis of people who present themselves for hospitalization. One way of looking at that is to look among everybody that has been hospitalized into ICUs and how many of them survive. In Pakistan, this figure is low, because of our inability to provide ventilator support. I have been trying to find out how many people have gone on to ventilation and how many have come off, but to my knowledge nobody has, to date, compiled that data. Here in the US, two-thirds of all people who went to the ventilators never came off and in some hospitals no one did.

It’s only now that we are beginning to see, thanks to valuable experience and with some highly-skilled people in the hospitals, some favorable improvements in case fatality rate for those who are hospitalized. But the overall numbers that you see being reported are the figures that are extrapolated to population level, which we are not doing in Pakistan. And unless you are testing very widely, you are groping in the dark. Now, I am not saying that developing countries like Pakistan can afford the level of testing being done in the developed countries, but we have to innovate, we need to look at other ways to do it.

And that is why our modeling becomes even more important. Epidemiological projections are very important to capture the entire dynamics of the infection, so that we know where we are going and therefore spread our medical assets accordingly. My understanding is that we only have around a maximum of five million tests at hand in Pakistan. That is not surprising because these tests cost a lot. This is a precious commodity and it has to be used widely.

BRR: There is some debate about fatalities related to COVID-19. What can be a better methodology to capture this mortality data?

ZAB: The reporting system for deaths globally is a lot more exact than what we currently have in Pakistan. We need to develop SOPs in terms of how we need to identify deaths from COVID-19. We should have set up a mortality reporting system at least a month ago, even if from hospitals, but we still don’t have such a system. Such a system should be tasked with centrally reporting, categorizing, tracking and researching all COVID-19 related or suspected deaths, since not all are being tested. All hospitals and emergency services like Edhi Foundation need to be made part of such a system.

BRR: How do you look at apprehensions that are now coming out of the US that there might be chances of second and third wave of this coronavirus?

ZAB: I think those are very reasonable epidemiological assumptions. Previous viruses which have caused global pandemics like the Spanish Flu also had a second and third wave. Many people don’t know, but the majority of deaths in the British India from that flu occurred in the second wave at that time. A cyclical pattern is possible for SARS-COV-II as well. If you look through some of our model projections, they do also simulate a slight upsurge, but that’s related to measures related to social distancing and other restrictions going down in intensity. But overall, the risk of further outbreak is there and it is one of the main reasons why our precautions and life style changes need to continue.

BRR: Has this first wave prepared people better for the coming waves?

ZAB: Yes, I think we will get more time and we will be better prepared. People will adjust and learn. And the new normal won’t be the same as the current normal. My problem right now is that this is the time in Pakistan’s history where we need leadership that is not confused and not in conflict with itself. Whether or not we are able to convince people to practice all preventive measures is critically important right now. We cannot be giving mixed messages to people by telling them yes, social distancing is important, and then telling them yes, you can have congregations and communal prayers like taraweeh. That sends such a wrong message, making a mockery of everything by not basing decisions on science and evidence.

This is what I am struggling to make people understand. I am afraid that we have been unable to implement policies or to convince people on even simple things, like Friday prayers and other congregations. We are not necessarily better Muslims than Muslims in other countries. If Saudi Arabia, where the Holy Mosques are located, can implement these evidence-based strategies in an absolutely nonpartisan manner and also get the community to accept it, then what is the issue here in Pakistan? We don’t practice a different form of religion than other Muslim countries, do we?

This is the time that the leadership of the nation needs to speak with one voice. This is not the time when we can afford these kind of fractures in this society, because these divisions will come back to haunt us.

BRR: How do you categorize Pakistan’s current status in terms of social distancing?

ZAB: I think we are in a flexible kind of a model right now, as we have been unable to implement strict social distancing or physical distancing measures. And my worry is that this flexible mode is also going to change dramatically. There is no question that we have been able to implement some measures of partial lockdown, but at a huge economic cost. Where we are currently, the case for some kind of a flexible reopening in the next two weeks becomes strong. I still feel very strongly that we should not relax further at this stage, because we are just at the beginning of the upsurge of cases in Punjab and Sindh. Perhaps by the middle or end of Ramazan, the government can reopen things a little bit.

BRR: Do you think that the taraweeh prayers are going to increase the risk of infections?

ZAB: I don’t want to single out taraweeh prayers, but any communal activity, such as people going to the large markets and congregations, is a total mistake in these times. Once you allow something like this, you cannot stop your more elderly and more religious people from going there. I want the people who make these decisions to imagine if it was their father or grandfather that they would send to these communal gatherings, knowing that they might be exposed to the virus. Just put yourself in those shoes and ask this question. Can you then give out this message that it is okay for others to do the same? If not, people need to rethink.

BRR: Can Pakistan’s healthcare system cope with hospitalizations? For instance, the ventilator availability is said to be low, with different numbers floating around.

ZAB: Realistically speaking, and we don’t say that out loud, but we won’t be able to provide intensive care or ventilator care to everybody in the country. Sixty to seventy percent of your rural population lives hours, if not days, away from any specialized care. Most district-level hospitals don’t have any facilities for prolonged respiratory care. So, just putting in another 3,000 ventilators in the system when we don’t have the people and the equipment to support ventilator care does nothing.

As I previously mentioned, until very recently in the US, about two-thirds of patients who went to ventilators never survived. And remember, most of the deaths from COVID-19 are not due to respiratory problems alone, but due to cytokine storm, clotting disorders or just the body immune response destroying itself. Therefore, I think that the debate about ventilators is a distraction. We do need to have ICU support for critical care, but by the time people get to it, it is too late. We should put maximum effort in the country into preventive strategies.

BRR: Countries that have done better in taming this coronavirus have in common their ability to test a lot many people early on in the outbreak. How can Pakistan ramp up its testing capacity, given the huge requirements for lab capacity, qualified staff, PPE, and failsafe SOPs?

ZAB: And you need money, on top of everything you mentioned. I think we need to utilize our resources very intelligently, as we already have about 5 million tests available. If I was the government with those assets available, I would have used some of those assets for testing high-risk people, frontline healthcare workers and high-risk categories like travellers or pilgrims. But I would have also used a portion of those assets to conduct some very rapid population-level assessment on the basis of strategic sample selection. We need to have an idea how rampant is the virus in different areas and how is it changing over time. That kind of data in Pakistan was needed. It is still not too late. We ourselves are interested in conducting such population-level studies to see where we are with respect to virus hotspots and people’s immunity against the virus.

BRR: We are seeing friction, even in developed countries like the US, on whether it is the federal government’s job or the states’ responsibility to level up testing for SARS-COV-II. In Pakistan’s context, whose job is it really to ramp up testing: federal government or provincial governments?

ZAB: It starts off with respectful collaboration and cooperation and an end to what I have called out as “interminable bickering”. It is so depressing to watch Pakistan’s divisive political discourse at a time of national crisis. This is a warlike situation, but we are spending our energies on debating trivialities. I would like to see the politicians put their differences aside because they are creating confusion and demoralizing people.

Decision-making cannot be whimsical – you have to take your scientists seriously. Right now, there is more focus on logistics and implementation than really seriously exploring what our policy options are and what is the basis for it using epidemiology. Additionally, there has not been a single model that the government is working from that has been made public for scrutiny and debate. The kind of dialogue and discussion that occurs between governments and academic bodies globally is just not happening in Pakistan. We need to utilize whatever research and academic capacity is available in the country.

BRR: There are countless clinical trials going on and people are desperate to know where things stand on vaccines and therapies. Between prevention pharma (vaccines) and treatment pharma (medicinal therapies), which relief do you think may come first?

ZAB: Honest answer is that vaccines and effective medicines are still some time off. It is human nature to jump at every option as being the panacea, but there isn’t a panacea yet. Remdesivir by Gilead has shown some promising results, but we have to wait for the randomized controlled trials. Full marks to the researchers who are doing this work, but this has to be done scientifically, whether it is drugs, antibodies, or plasma therapy. And even when these drugs get approved, I can guarantee you that their access within Pakistan is not going to be as high as access in countries that are in the middle of outbreak now. Just like the HIV therapy, it will be some time before developing countries like Pakistan get access to it.

As for vaccines, you may be surprised that there are things underway right now that might provide some vaccine options by this fall. A group of scientists at Oxford is working on human trials now, which might fast-track the development of vaccine. But again, as I said, developing a vaccine and having it available to the world are two different things. And therefore I would not, in any scenario, make any allowance for these drugs or these vaccines being available to us within this year.

BRR: The question then arises over the longevity of this pandemic. We understand that the situation is evolving, but what’s your expectation as to how long will SARS-COV-II stick around?

ZAB: In Pakistan, the peak is just starting. What the government is trying to do is to have a phased and strategic opening of the economy, which I think is necessary, because you cannot just leave people at home under strict social distancing for a long time. Our modified model, which is based on what the government is doing, suggests that we are looking at potentially being able to control the peak of this infection by hopefully June to July, depending upon stringent implementation of policies.

Under the Exit Strategy in our dynamic model, which is a one-month period of high compliance followed by gradual reopening, case fatalities or total deaths range from 30,000 to 40,000. We may get a second peak later on, but it may not significantly impact things. But this scenario continues with infections, hospitalizations, and self-isolation protocols right until the beginning of next year. The assumption in our model is that everyone will behave; there will be no large-scale gatherings, communal prayers, religious ijtimaas or sporting events; people will wash hands, wear masks, and maintain hygiene; and government will have an intelligent reporting and tracking mechanism for clusters of cases or hotspots that are promptly isolated or quarantined. All of these conditionalities will need to be met.

BRR: Can you please explain the exit strategy in your model a bit more?

ZAB: We will explain this fully in the publication. This exit strategy is a science-based modification of what the government is trying to do. If I were in the government, I would reopen the economy step by step. First, allow people who are relatively young to go out for work, as they will be at low risk of adverse outcome. Then, open up sectors like construction, farming, some industries and essential services that can practice social distancing. It’s a gradual reopening of the economy while protecting the elderly who are at high risk. Under this model, it is assumed there will be some identification and tracking system that isolates exposed people, besides protecting frontline healthcare workers. And we also take into account realistic health system capacity for quality intensive care.