Ibrahim Darwish and Ahmed Maher, two young physicians from Ain Shams University in Cairo, joined four other colleagues in a minivan provided by the Ministry of Health to drive to Ismailia to be stationed for two weeks at the Abu Khalifa Hospital recently, this being one of the hospitals designated by the ministry for the treatment and isolation of individuals infected with the Covid-19 virus. A lung specialist and a specialist in intensive care, Ibrahim and Maher are no strangers to tough respiratory cases. For a decade, they have attended critical-condition patients in the hospitals of Ain Shams University. However, this time things seemed different. “I have worked with patients with threatening chest infections before, but never before have I been in a situation where I would have to try to treat people who have been infected with a virus that the world is still trying to learn about,” Darwish said. It was a little less than a month after the Egyptian authorities had officially announced the first case of Covid-19 in Egypt on 14 February that Ibrahim and Maher were nominated by their departments to join the main medical team battling against the spread of the virus. Neither hesitated before agreeing to take up the assignment. “It was daunting and challenging, but it was not something I would have turned down,” Maher said. Both physicians feared for their parents. Ibrahim chose not to inform his mother and father because he thought that “the worry would kill them.” Maher felt it would be better to tell his mother and sister because this was his entire family. “They had to know because I did not really know what was going to happen,” he said. “We have seen what has been happening all over the world, with doctors and other members of medical teams getting infected and losing their lives in the battle against the new coronavirus,” Maher said. The fact that they were on a possibly life-threatening assignment was not the only thought they had in mind on the road from Cairo to Ismailia. They also feared an infection that could disrupt their young and promising careers. The one thing that Ibrahim, Darwish, and the rest of the group were mindful of was the possible development of the coronavirus in Egypt and the ability of the health system to deal with any seriously challenging situation. Mohamed With the large industrial countries facing a tough time in treating people infected with the new virus, these two doctors, who had been working in one of the country's leading university hospitals, knew only too well what a massive influx of patients could do and were praying that things would not get out of hand. ABU KHALIFA: Ahead of going to the Abu Khalifa Hospital in Ismailia, the Ain Shams University team had been informed by medical officials about the Covid-19 virus and the possible protocols to be applied in the absence of any approved treatment for the illness. “But it all seemed so vague because we knew we were basically going to be doing our best to save lives,” Ibrahim said. “We would have to do this in a hospital where we hadn't worked before, so we were not familiar with the staff or the capacity of the hospital, and this was an added worry,” he added. Upon their arrival at the hospital, Ibrahim and Maher were reassured that the nursing teams were up to the job. Protective gear was available, and the infection-control expertise seemed to be in a good shape, both physicians said. “Everybody seemed dedicated, scared maybe, or at least worried, but seeming to know that these were not normal times, and we were not in an easy situation,” Maher said. The intensive care unit, Maher added, was well equipped. The question, however, was more about the ability of the medical team to keep patients from reaching the point where they needed it, because this would mean the virus had hit the lower respiratory tract, risking acute pneumonia, respiratory failure, and maybe renal and liver failure as well. Ibrahim and other doctors were trying hard to help patients who were either largely asymptomatic but had pre-existing health conditions that put them at risk of possible complications or had mild to stronger symptoms to recover. It was an experimental exercise, because while there was a designated protocol for medication there was no one prescription that fitted every single patient. “There is no single medicine yet to treat this new virus. There is no clear understanding of its mechanism, and there are so many variables that relate to the age bracket, the overall health, and the medical history of each and every patient,” Ibrahim said. Mostly, the initial protocol is based on different combinations of oseltamavir, an antiviral that blocks the action of several types of influenza along with paracetamol and in some cases antibiotics. The objective is to stop the virus and block it from reaching the lower respiratory system, because if it does so it is likely to start blocking the air passages inside the lungs, prompting a cytokine storm. This is an uncontrolled immune response that can lead to acute respiratory distress and organ failure. The job of the team at the Abu Khalifa Hospital is to make sure that patients admitted with Covid-19 avoid such issues, being alert and capable enough to spot and treat it promptly before it becomes fatal. Every time Ibrahim has to send a patient with a cytokine storm to intensive care, he is not sure of the chances for the patient to make it back to his room. It can be less than a 50 per cent chance for a patient who is not under 50 years old and who is not otherwise physically fit and does not smoke to beat this cytokine storm, Maher said. It was on his fifth day at the Abu Khalifa Hospital that Maher lost his first patient, a foreigner who had been admitted after having tested positive for Covid-19 during a precautionary screening process conducted on holidaymakers at a tourism facility where others had tested positive after leaving Egypt. The patient was in his mid-50s but was quite overweight and had a considerable smoking history. This was not the first time for Maher to order the life-support machines to be turned off on a patient. However, it was a shocking moment. “It was not about his prognosis, but rather about the fact that we lost him to a disease for which the world has yet no vaccine and no medicine,” Maher said. By the time Maher and Ibrahim finished their two weeks at the Abu Khalifa Hospital, the team had lost five of 50 patients they had treated. Some had had a good response to the medication from the beginning and tested negative in a relatively short time; others went to intensive care and came back to get better and move towards testing negative; but some had to close their eyes for ever after a few days in intensive care where they were not allowed visits by family or friends. On their way back from the hospital earlier this week, the team from Ain Shams University had to go through a series of tests to make sure they tested negative for the virus. “This was a concern because while we know that this virus is transmitted through droplets and not airborne, we also know that it is a virus that the world is still trying to learn about,” Ibrahim said. Back in Cairo, Ibrahim, Maher, and the rest of the team had to go into self-isolation. They were not allowed to see their parents to reassure them. They then had to have further tests before being allowed back to the wards of the Al-Demerdash Hospital where they had been practicing. Would they agree to go back? Both offered an unhesitant “yes”. “At moments it was quite depressing, but there were also moments of joy when patients would start to get better or test negative,” Ibrahim said. Maher CASES: This week, the Ministry of Health increased the number of hospitals in Egypt designated for the treatment of patients infected with the new coronavirus from five to nine. Patients referred to these hospitals are those who test positive for the virus at Ministry of Health laboratories. The testing is done of individuals with clear symptoms who seek the advice of hospitals in each governorate or by a decision of the medical team assigned to hotlines designated by the Ministry of Health or on the recommendation of practicing physicians. As Al-Ahram Weekly went to press, the officially announced number of cases of Covid-19 in Egypt had well surpassed 660, with close to one third of cases having since tested negative and around 15 per cent having fully recovered. The death rate has been around six per cent. The Ministry of Health has denied all allegations of hiding information about the number of cases and insists that all details are shared with the World Health Organisation (WHO). Some medical doctors who spoke on condition of anonymity argued that whatever the Ministry of Health said accurately reflected the figures reported to it. Some suspected cases do not go through the testing process, either because their symptoms are too mild or because they decline to do so. According to one of these doctors, over the past six weeks, he had recommended a few patients to get the test, but they had declined. “I managed to help some because their symptoms were mild.” This doctor would have wished to see other patients overcoming their inhibition to do the testing and be admitted in the designated hospitals if need be — “because they needed intensive care” to overcome severe pneumonia whether it was caused by COVID-19 or not. The fear of ending up in one of the designated hospitals, this doctor said, was not just about a patient's inhibition about the quality of care and accommodation they might receive, but also about the fear of dying alone away from a last good-bye or even from the presence of family. “It was a very harsh moment for me when the husband of one patient looked at me and said that if he sent his wife to one of the Covid-19 designated hospitals she would die there alone,” another doctor said. The patient had solicited medical help after having suffered symptoms. For this experienced doctor, the scans indicated a grave problem, and it was just a few days after she was last at his clinic that she passed away. Neither the patient nor her husband agreed to do the test for the new coronavirus. Nor did the husband agree to do it after he lost his wife. As far as the husband of the patient was concerned, his wife had died from severe pneumonia. He accorded her a decent farewell. Physicians who treat patients who either test positive for Covid-19 or who decline to take the test observe very strict disinfection routines. Private hospitals that receive patients who test positive for Covid-19 have to close for a thorough disinfection process following the regulations of the Ministry of Health. Last week, one private hospital declined to do a test on a patient who was admitted and treated for over a week with acute and worsening pneumonia. The patient passed away after a week in intensive care amid complaints from the family that the management of the hospital had decided to overlook the possibility of Covid-19 as it did not want to close down for disinfection. For its part, the family had not solicited the help of the Ministry of Health in any way. “It has been a week, and none of us has shown symptoms, but if any of us showed the least symptoms we would certainly go for the test. We don't know if it was the new coronavirus; it might not have been, but we thought it would have been wise to do the test,” the son of the patient said. “Maybe if they had done the test, there would have been something that could have been done. I don't know: a farewell to one's own mother is heartbreaking,” he added. “Farewells are particularly hard these days,” said Hossam, an attendant at an eastern Cairo cemetery. With the current restrictions imposed by the state, funeral prayers for Muslims and Christians are allowed neither in mosques nor in churches. Only an abridged version of the religious ceremony is allowed at hospitals and burial places. On Sunday, Hossam was preparing for the burial of a woman who he suspected had passed away after having been infected with coronavirus. The family had not notified the attendant of the cemetery, but the fact that they required that he and all those who helped him wear masks and gloves meant something to him. At the burial, every single person was wearing masks and gloves. The reciter of the Quran who usually recites prayers at a burial was asked to keep an atypically significant distance. Grieving family members were also keeping a significant distance from one another in this situation. SCENARIOS: Professor of lung diseases at Ain Shams University in Cairo Adel Khattab thinks that if the infection rate peaks in Egypt, “possibly around the second half of April,” the overall cases that fail to survive Covid-19 will not be as high as in other countries. This assessment, he said, was not just about the recorded deaths in the past six weeks since the first case of the new coronavirus was officially announced in Egypt but on the rate of infection. “As in any country, the cases that are recorded are not all the cases there are, because some people don't seek medical help. But even if one were to assume that the actual cases were double or even triple the cases that get recorded, we could still claim that we are not running into a disaster,” Khattab argued. This, he added, might be due to the fact that the majority of Egypt's population of 100 million is under the age of 35. It was also about the fact that there is growing reason to believe that populations that have mandatory vaccine programmes against TB are less vulnerable to be infected with the new coronavirus or are more capable to survive it. “Covid-19 is a virus, and TB is a disease caused by a bacterium, but it seems that the TB vaccine helps the performance of the immune system in the face of Covid-19,” Khattab said. “There are also experimental protocols with medicines that have been used to treat malaria, and there is a whole range of attempts all over the world to come up with a vaccine or a medicine,” Khattab added. At the laboratories of the National Research Centre in Cairo, clinical pharmacologist Bassem Mohamed and virologist Mohamed Ahmed are working hard to help contribute to the research to find an answer to the woes of the pandemic. Mohamed is hard at work on an eight-week project to develop a substance that could strip the virus of the protein that keeps it alive and capable of attaching itself to human cell receptors. Last year, with a group of researchers in North America, Mohamed managed to prove the possibility of using a substance of this sort to neutralise the Zika virus, which is significantly less ferocious than Covid-19. “This is not to say that in eight weeks we will have the answer, but in eight weeks we will have moved ahead with trials to reach the animal-testing threshold,” he said. In parallel, Ahmed is trying to harness his experience with the Middle East Respiratory Syndrome coronavirus (MERS-CoV), for which he helped develop a vaccine, in the combat against Covid-19. Not an easy job, he argued. “There are similarities between MERS-CoV and Covid-19, but we need to cut through the details of Covid-19 to be able to defeat it. This is not something that will happen overnight, but we are working very hard,” Ahmed said. Meanwhile, he added, doctors will have to keep trying alternatives to compensate for the inability of the human immune system to face up to Covid-19 in some cases. “The virus itself is not necessarily aggressive. It is actually relatively mild, but our immune system doesn't have the memory of the antibodies required to stop it. So, in the absence of a vaccine, Covid-19 keeps circulating,” he added. While hoping for the best-case scenario whereby the number of cases in Egypt do not surpass a few thousand by the end of May or mid-June when the infection rate should start to decline, the Ministry of Health is also preparing for a worst-case scenario. “With such a huge drama worldwide, all countries have to be prepared. This is not to say that we are anticipating disaster; it means that we are facing a situation that could get better gradually or get worse suddenly,” said one source at the ministry. Alerted by seeing “some of the world's best medical systems cracking under the pressure of Covid-19,” the ministry has been putting together an emergency plan, he added. This includes a list of hospitals that could be allocated for the treatment of the coronavirus as the numbers get bigger. “We anticipate we would have at the most 1,500 cases by mid-April, but we are planning to handle a lot more than this,” he said. The plan also includes allocating more space in the intensive care units of the leading public and university hospitals, better equipping them, providing more medical supplies, and “in the next month increasing the number of ventilators available,” he added. According to Ismail Mohamed, head of the central intensive care division at the Al-Demerdash Hospital, all the leading hospitals have been creating more space for possible emergencies. For example, he said, operations that are not considered urgent are being rescheduled to relieve the stress on hospitals. All the leading hospitals are also working to decrease the possible exposure of patients to the virus by reducing hours for clinical visits at outpatient clinics. Reducing exposure is something that the entire medical service, both public and private, is observing. Surgeon Osama Al-Atrash, who operates at the Ain Shams Hospital and at some private hospitals, said he had been rescheduling most of his non-urgent surgeries. “All except the oncology surgeries, because those cannot be put off,” he said. During the past few days, Al-Atrash has been consulting through video-conference with anesthetists and oncologists on the management of cases. He has also reduced the working hours at his private clinic by close to one third, only giving time for either emergency cases or oncology surgeries. Khaled Samir, a cardiac surgeon, is also trying to reschedule his list of operations “as much as possible. The trouble is that every operation, especially if it is cardiac, requires an intensive care bed for at least a few days. Now we have to worry about occupancy, which is always a challenge even on the best of days, and we also have to worry about waiting lists, especially in the public hospitals that cover the majority of patients,” he said. However, as both Al-Atrash and Samir noted, cancer patients and cardiac patients are among the high-risk groups for Covid-19 infection. And a similarly challenging situation faces gynecologists and obstetricians. Pregnant women need regular medical visits, and couples opting for IVF techniques need even more frequent medical visits and tests. Haitham Al-Tanawy is an obstetrician-gynaecologist who works for a leading private medical service in Cairo. He said that as of last week there had been a significant drop in the number of allowed medical visits to pregnant women, adding that all non-urgent cases had been asked to delay their visits and pregnant women in stable condition were having their visits further apart than usual but had been provided with more regular telephone follow-up and counseling. Only pregnant women with challenging conditions were allowed relatively frequent medical visits. Meanwhile, couples about to initiate IVF procedures were asked to delay the process. “We have chosen to observe the international protocol on visits for gynecologists and obstetricians. This is a new virus, and nobody knows for sure the kind of impact it can have. Pregnant women are not just asked to decline their visits to clinics, but are also required to strictly observe the rules of social-distancing,” Al-Tanawy said. Meanwhile, he added, women who go through labour will receive telephone advice until it is absolutely necessary for them to go to hospital. Provided that there are no complications, they will be discharged after natural or caesarean births as soon as medically possible. This new set-up is difficult for some women. Rola, a 28-year-old who is expecting her first baby in the first or second week of April, said she was “devastated”. “I will have to go at the very last minute, and given that I am expecting a natural birth, my doctor said he would want me to leave hospital within 24 hours. Family and friends are not allowed to come to see the baby, and I am only allowed to go with my husband and my mother as this is a maternity hospital I am going to,” she said. “This whole situation is stripping me of part of the joy of my first baby. Of course, I am scared and disappointed as it is so unfortunate. I am not even sure when I can have a baby shower. Children who are born at this time will always be remembered as the children of the coronavirus,” Rola concluded. *A version of this article appears in print in the 2 April, 2020 edition of Al-Ahram Weekly
