Personal Protective Equipment is a Mandatory Requirement: A Perspective from Pakistani Physicians
My team and I have thoroughly read the editorial published by Karlsson and colleagues.  It raises pressing issues in the current pandemic scenario, where the disease burden has negatively affected healthcare budgets, healthcare delivery, and raised the overall global economic burden. With the rapid increase in the number of COVID-19 cases in Pakistan, it remains vital that frontline healthcare workers should be provided with adequate personal protective equipment (PPE). We agree with the main theme of the editorial which emphasizes that providing adequate PPE and training helps alleviate the chances of infections in healthcare workers.  However, to assume based on a few studies that providing PPE to healthcare workers ensures no chance of infection is presumably incorrect. Despite adequate PPE availability and training, it is still possible that many healthcare workers will contract COVID-19. Even though adequate PPE materials are provided to healthcare personnel, many other factors must be considered when analyzing the reduction of infection risk in healthcare personnel. We believe that the quality of PPE training and PPE materials must also be taken in to account.
Agreeing with the main notion that PPE is a vital requirement which the hospital administrations and governments must procure for their frontline healthcare workers, Pakistan has failed to provide their healthcare workers with this basic safety necessity. As per a study conducted by Ahmed et al., only 37.4% of doctors in Pakistan have access to masks/ N95 respirators.  Furthermore, only 34.5% have access to gloves, 13.8% to face-shields or googles, and 12.9% to full suit/gowns.  It has also been noted that 60.3% of physicians have had to reuse PPE.  Alarmingly, 50.6% of physicians in Pakistan have been forced to work without PPE.  The above data paints a bleak picture of the essential safety of healthcare workers across Pakistan. This has caused unrest at the administrative, social, and political levels. As a consequence, there has been a sharp rise in the number of COVID-19 infections in healthcare workers. As of July 10, the number of infected healthcare workers has risen to 6025.  More specifically, the majority of healthcare workers who tested positive belong to Khyber Pakhtunkhwa (1986 cases), Sindh (1752 cases), and Punjab (1100 cases).  The estimated mortality has been recorded at 69 healthcare workers.  The majority of the healthcare workers have died in Sindh. 
We believe the current government and various administrations have not taken the task of healthcare personnel safety seriously. We believe the shortage of PPE has occurred due to multiple reasons. One of the many reasons accounting for the shortage of PPE seems to be discrimination. There have been multiple reports suggesting that a lack of seniority in position is contributing to this shortage and putting junior medical officers at risk. It is also possible that the biased distribution of resources has also occurred based on a political agenda. The fear of uncertainty among the population has resulted in panic buy and hoarding of PPE supplies. As a consequence, the manufacturing divisions have had immense trouble in trying to keep up with supply production. Despite the efforts of various NGOs in Pakistan, the protection of Pakistani healthcare workers is nowhere near international standards.
Overall, physicians in Pakistan fear that they might transmit this infection to their loved ones. The inept policies and inadequate PPE availability are slowly starting to damage the healthcare sector in Pakistan. It has been reported that 46% of Pakistani physicians are likely to quit their job due to a lack of PPE.  We recommend that the general public must be educated about the importance of PPE for healthcare workers. There must be a supervised system in place for the distribution of PPE amongst healthcare care workers. The issue of lack of PPE availability for all physicians must be raised on all international forums worldwide. This is because increased rates of infection in healthcare personnel can eventually reduce the healthcare workforce and effectively cripple the healthcare system.
1. Karlsson Ulf, Fraenkel Carl-Johan. Complete protection from COVID-19 is possible for health workers BMJ 2020; 370:m2641
2. Ahmed J, Malik F, Bin Arif T, et al. (June 10, 2020) Availability of Personal Protective Equipment (PPE) Among US and Pakistani Doctors in COVID-19 Pandemic. Cureus 12(6): e8550. doi:10.7759/cureus.8550
Competing interests: No competing interests