he risk for epidemics is increasing in direct proportion with the rise in global travel and trade. Pathogens travel visa-free across countries and continents. A strong public health infrastructure equipped with relevant professionals and expertise is pertinent for timely identification of risks and detection of emergence of an outbreak followed by mitigation measures and a structured response, respectively.
Pakistan has a wide network of health infrastructure starting from the community level up to the tertiary care hospitals and institutes. At the community level, there are lady health workers (LHWs), outreach vaccinators, communicable disease control (CDC) supervisors, and other health staff. The total number of regular outreach staff working for health sector in Pakistan is over a hundred thousand. These workers visit households and communities in their areas according to well-defined protocols. At the primary healthcare (PHC) level, there are around 5,500 basic health units (BHUs) and 700 rural health centres (RHCs) manned by medical and para-medical staff. At the secondary and tertiary healthcare level around 1,200 hospitals are providing clinical services. Each tertiary hospital is attached to a medical college or university. Special institutions also fall under the category of tertiary care.
Each category of the above-mentioned service delivery levels has its own role to play in epidemic situations. For example, community level surveillance is regularly conducted through the LHWs, CDC supervisors, sanitary inspectors and dengue fever workers. These outreach workers played an important role in surveillance and awareness raising during the Covid-19 outbreak. The vaccinators, who fall under the domain of the immunisation programme, are responsible for surveillance of vaccine preventable diseases. Clinical care for active cases of any epidemic is provided through the secondary and tertiary level hospitals, while outdoor services are provided at the hospitals as well as at PHC facilities.
The National Institute of Health (NIH) and provincial Institutes of Public Health (IPH) play a central role in disease surveillance and response. The NIH hosts the Centre for Disease Control (CDC) as well as the National Command and Operation Centre (NCOC). It is also the focal point for Global Health Security Agenda (GHSA) related activities in Pakistan. A robust two-year training programme is also run by the NIH to train medical professionals in epidemic preparedness and response, in collaboration with the CDC USA. This Field Epidemiology and Laboratory Training Programme (FELTP) has produced over 200 graduates since its inception.
A national list of mandatory reportable and notifiable diseases is issued by the NIH. Every health worker and health facility is required to report these cases according to an elaborate protocol. The frequency of reporting varies from “immediate” to “weekly” depending on the disease. All health professionals are supposed to know these diseases, their definitions and reporting procedures.
Although the health infrastructure and professionals are reasonably placed across the country, a lot needs to be done in the domain of epidemic preparedness. Our general trend is a delayed response and immediate firefighting on a disease-to-disease basis. The capacity of our health system to identify and immediately report notifiable diseases is not up-to-the-mark, especially at the provincial and district levels. The provincial Institutes of Public Health need to upgrade their capacities so that they are able to train and equip the district level staff.
An important aspect of epidemic preparedness is health-security readiness of ports of entry (airports, seaports and border crossings). A health-secure port is one where disease, pathogens and vector transmission are controlled through measures like screening of incoming visitors, screening of food supplies and screening of all containers/ cargo for vectors like mosquitoes, rats etc. The capacities in terms of infrastructure and human resources required for such screenings at our airports, and especially seaports and ground-crossings, are weak. Usually, there is no more than a ceremonial screening counter at the ports.
Despite the weaknesses in epidemic preparedness, Pakistan’s overall response to the Covid-19 crisis was appreciable. The government was able to set up a system quickly and our track and trace approach helped keep the disease confined, unlike some countries with similar demographics and health systems. Legislations for epidemic control were established/ updated through various ordinances in each of the provinces within months of the onset of the epidemic. However, these ordinances and laws were developed in a fire-fighting mode when the pandemic had already arrived. It would be wise to have such laws, rules and regulations in place to be better equipped and better prepared for future epidemics.
Epidemic preparedness is not just about resources being available and placed appropriately; it is a matter of taking every suspected health event seriously. For example, screening the temperature of incoming passengers might appear to be a minor step and hence easily ignored. Similarly, sanitisation and disinfection of containers might appear to be a tedious and futile exercise. However, these apparently minor steps, if ignored, risk turning into catastrophic events within a short span of time, leading to loss of health and valuable resources. Inculcation of a sense of responsibility and attention to detail is important.
The government has a responsibility to set up appropriate infrastructure and ensure the availability of trained human resources. At the same time, it is the duty of public at large to observe the notified screening protocols and standard operating procedures. Pandemics and epidemics cannot be prevented by governments alone; all of us, global citizens, have a duty in this regard.
The writer is providing technical support to the Government of the Punjab in strengthening their immunisation programme. He can be reached at [email protected]