“I have a linen mask. If I see someone coughing or sneezing, I wear it. But other than that, no. The whole situation cannot handle further suffocation. This sunlight we’re standing in will melt the coronavirus,” said Mohamed Omran, a shoe and handbag seller in one of Attaba’s alleyways in downtown Cairo, when Mada Masr asked him about how he protects himself from COVID-19 at work.
On May 6, Mada Masr took a morning tour of the street opposite the Attaba parking lot, known as the Ruwaie Household Goods Market. There was the usual overcrowding in markets and shops in the days before major holidays. Apart from some vendors and customers wearing linen masks and discolored medical masks on top of their foreheads or below their chins, there was no distinguishable difference from how the market normally looked prior to the outbreak of COVID-19.
“The government said to ‘coexist with corona,’ and what is meant to be will be,” says Omran, who is over 50, sharply answering my question on whether or not he follows the Health Ministry’s daily statement on the number of new infections and deaths caused by COVID-19, as well as the ministry’s advice on social distancing.
At the beginning of May, the daily number of reported cases crossed the 300-person mark for the first time. On May 1, the ministry recorded 358 new COVID-19 cases, an 87-case jump from the previous day. On May 2 and 3, the numbers decreased, only to jump back to 348 new cases on May 4. Since then, the daily tally has continued to increase, surpassing 700 cases on May 19.
The government greeted the onset of Ramadan with slogans about the coexistence with and adaptation to COVID-19. A month after imposing a partial curfew, along with the complete closure of government service offices, commercial centers, cafes and restaurants, social distancing at state agencies and the endless calls to “stay at home,” the government made an about-face in strategy on April 23.
The government eased its precautionary measures to curb the virus outbreak by reducing curfew hours and opening shopping centers and other establishments, but cases continued to rise — the Health Ministry has considered 500 new positives per day the peak of the outbreak, which Egypt reached and then surpassed this week — the government did not reverse its decision to reduce curfew hours. Rather, it occupied a gray zone of both defending the necessity of resuming economic activities and mitigating the spread of the novel coronavirus, citing the collapse of economies where governments imposed a full lockdown.
Amid myriad calls for the government to impose a total curfew in the next two weeks and ease the precautionary measures after Eid al-Fitr, the Health Ministry published its “Coexistence with COVID-19” plan on May 13 before retracting it hours later, citing a need to present it to the Cabinet Crisis Committee. Nonetheless, the plan presents a look into the government’s thinking on how a gradual return to normal life will happen, even if there isn’t yet a specific timeline.
The plan is divided into three phases. The first phase, which will begin as soon as the plan is approved, involves what are called “strict measures to avoid setbacks.”. This phase will be in place until there is a decrease in the number of new registered cases across the country for two consecutive weeks.
Measures for the first phase include: mandatory temperature screenings at the entryways of different facilities, including metro and train stations; people must wear masks in public places or face a LE4,000 fine; disinfectants and hand sanitizers installed in malls and shops; the crowds inside different facilities and commercial stores be reduced; and cinemas, theaters, cafes and other recreational facilities remain closed.
The second phase, titled the “intermediate measures” phase, will begin at the end of the first phase and will last 28 days. Phase two would allow some activities to resume under certain conditions — restaurants would be allowed to operate at 50 percent capacity, for example. The third and last phase, called the “lenient and continuous measures” phase, would go into effect unless and until other measures are implemented, or the World Health Organization’s global risk assessment of COVID-19 drops to a low level.
In this report, Mada Masr looks at the government’s “coexisting with the coronavirus” plan. We follow what the Health Ministry has announced and retracted over the last few days and the measures it has begun to implement, and find out why the ministry has altered its strategy to combat COVID-19.
In the latest plan, the Health Ministry announced it would close all quarantine hospitals by mid-June and replace them with fever and pulmonary hospitals nationwide in three phases.
According to the director of a fever hospital who spoke to Mada Masr, Health Minister Hala Zayed informed the directors of all fever hospitals during a video conference call on April 23 that their hospitals will be converted to quarantine hospitals. She asked them to prepare lists of workers in each hospital, isolation beds, ICU beds and ventilators, in addition to the x-ray and testing equipment required to evaluate cases in the pre- and post-quarantine stages. She also asked them to identify suitable spaces for reception tents in front of each hospital for patients suspected of having COVID-19, while taking all measures necessary to prevent transmission. The ministry would simultaneously begin to increase these hospitals’ capacity.
The fever hospital director says that 32 fever hospitals across the country will be converted to handle COVID-19 cases in three phases between May and July. With the start of each stage, the fever hospitals will take the quarantine hospitals in their area out of commission for COVID-19 cases.
The source explains to Mada Masr that the ministry changed its initial COVID-19 strategy because the preventive medicine sector couldn’t handle the increasing infection rates. The preventive medicine sector has long been responsible for tracking index cases and managing airport quarantines for infectious diseases like yellow fever, SARS and malaria. Now, the source says, the ministry’s curative care will assume responsibility for dealing with COVID-19. The ministry’s initial strategy completely relied on the preventive medicine sector — the sector responsible for medical quarantine in airports and seaports, vaccinations in health units and fever and pulmonary hospitals across the country — to combat COVID-19. The source adds that only 10 percent of the ministry’s doctors work in the preventive medicine sector, and most are general practitioners.
In early February, the preventative medicine sector converted Nagila Hospital in Matrouh to a quarantine hospital, which was then followed by the decision to have fever and pulmonary hospitals receive suspected COVID-19 cases. It then made the decision to designate a hospital in nearly every governorate as quarantine hospitals. Then the ministry closed outpatient clinics in all hospitals and folded the medical staff of those clinics into the preventive medicine health units.
The hospital director points out that the preventive medicine sector’s main objective in the current stage is to track those who came in contact with confirmed COVID-19 cases by interviewing the patient’s possible contacts by phone. Ahmed al-Sobky, the minister of health’s assistant for public health, announced on May 4 that preventive medicine staff were following up with more than 900,000 citizens who have directly or indirectly been in contact with COVID-19 cases.
The director adds that converting fever and pulmonary hospitals into quarantine hospitals requires large medical teams with specialists to handle specific cases, including COVID-19 patients who are pregnant or have cardiovascular disease or cancer. This is why the responsibility has been shifted to the curative care sector, which administers all the public and central hospitals across Egypt and includes almost 90 percent of all the doctors who work in the ministry’s hospitals.
For Alaa Ghannam, a healthcare researcher and the director of the Right to Health program at the Egyptian Initiative for Personal Rights, the move from previously designated quarantine hospitals to fever hospitals is justified. He tells Mada Masr that it does not make sense to keep quarantine hospitals in remote places anymore because the virus has already entered the community transmission level. The fear right now is not from transmission, but rather from dangerous complications that some people will face. Under the new plan, those at risk of complications will be isolated in fever and pulmonary hospitals, whereas suspected cases and confirmed cases with mild symptoms will self-isolate in their homes or in Health Ministry-designated university dormitories.
Ghannam believes that the success of the decision to replace quarantine hospitals with fever hospitals will depend on the Health Ministry’s ability to upgrade the efficiency of fever and pulmonary hospitals in the coming days, which includes securing medical staff and providing sufficient medical equipment to care for COVID-19 patients with critical symptoms.
Ghannam points out that there are 80 fever and pulmonary hospitals across Egypt and that, per the minister’s statements, only 33 of them will operate during the first stage. If the Health Ministry were able to set up an average of 300 care beds in each hospital of the first phase, he says, this would amount to 9,000 beds, which could accommodate a daily infection rate between 400 and 500. If the infection rate continues to rise, the ministry could start increasing the capacity of the other 47 hospitals.
However, not everyone shares Ghannam’s view. A medical source in the Abbasiya Fever Hospital believes that the decision to switch to fever hospitals as the infection rate continues to increase reflects a lack of urgency as well as understanding of the mechanisms to reduce the number of recorded cases. The source tells Mada Masr that Abbasiya Fever Hospital, which is the biggest and oldest fever hospital in Egypt, originally had 60 ICU beds. A few months ago, the hospital acquired 30 more beds, bringing the total number of beds to 90. If 60 percent of a daily case uptick of 400 to 600 new patients are in Cairo and Giza, a single day’s confirmed caseload would fill the equivalent of four hospitals.
“What happens if a suspected case who suffers from critical symptoms goes to the hospital and doesn’t find a place? They would have two choices: either go back home or stay in the hallways or corners of the hospital, which would lead to overcrowding. In either scenario, those with COVID-19 may not receive the medical treatment they need or get tested,” the source says.
In its daily statement on May 8, the Health Ministry called on citizens experiencing symptoms to head to the nearest fever or pulmonary hospital to receive medical care or call two hotlines, 105 and 15335, set up by the ministry to respond to inquiries about COVID-19.
Hours before the Health Ministry announced on May 1 that there were 358 new confirmed cases of COVID-19, up 100 cases from the previous day, the ministry’s Facebook page published a new protocol to “treat patients inside their homes.”
The new protocol requires that patients who are asymptomatic or have mild symptoms stay at home for 14 days after testing positive or until symptoms have disappeared, which means that some positive COVID-19 cases will not be transferred to quarantine hospitals nor receive medical care.
Although this procedure lines up with the new guidelines issued by the World Health Organization that recommend self-isolation at home for cases with mild symptoms (mild cough or fever), while continuing to monitor the symptoms and heed national guidelines for self-isolation, the Health Ministry deleted the post from its Facebook page after a wide social media backlash ensued. On May 2, ministry spokesperson Khaled Megahed stated that the ministry has not decided to adopt such a protocol yet, and that what is being circulated on social media is “false and disastrous.” However, on the following day, the ministry published the same protocol in the form of an explainer video without specifying the date of its implementation.
“A Health Ministry delegation came and registered our names and phone numbers. They told us that we’ve been added to the ministry’s team to follow up with COVID-19 patients in their homes, and that they will train us on how to deal with those patients,” says a doctor in an Aswan hospital adding that that the ministry started preparing for home isolation procedures on May 5.
The fever hospital director believes that the ministry has no option but to resort to home isolation in conjunction with converting fever and pulmonary hospitals into quarantine hospitals, because all government hospitals, including fever and pulmonary hospitals, cannot possibly accommodate the number of expected cases. He added that the most optimistic estimates for Egypt are 200,000 recorded cases. Even in that scenario, the director says, the 80 ministry-designed fever and pulmonary hospitals will fill up quickly. In his view, it is more prudent for hospitals to only admit the elderly and those with chronic diseases because they are more vulnerable to serious complications from the virus.
Zayed considers the multiplicity of health strategies a reflection of the flexibility of Egypt’s healthcare system and its ability to accomodate a large number of COVID-19 cases at various stages. However, Alaa Ghannam believes that it is evidence of the ministry’s disorientation in the face of a rising infection rate and its desire to replicate the approach of countries like Sweden and Switzerland, which have pushed for self-isolation at home, with no regard for the specific circumstances of Egypt’s densely populated cities. The plan means the state will effectively abandon its responsibility to treat all citizens for free, Ghannam says..
I If coexistence with the virus leads to a second wave and a collapse of the healthcare system, then economic recovery will not benefit anyone, Ghannam argues. He believes the best option is to slowly return to normal life while strengthening the ability of the healthcare system to support COVID-19 patients and control the spread of infection over the coming period. According to Ghannam, a balance can be achieved if alternative methods of patient care are used. “Home isolation for those who can. Those who cannot can be placed in intermediate care facilities, university dormitories, hotels, or even inside tents that the ministry can set up for this purpose,” he states.
The third component of the COVID-19 coexistence plan consists of resuming regular healthcare services in all government and university hospitals, especially those that generate income for the Health and Higher Education ministries, in order to offset the financial losses experienced by those hospitals over the last few months. The ministry will also allow a limited number of private hospitals to administer paid medical care to COVID-19 patients who can afford it.
According to a source in the Curative Care Organization, the decision to close down outpatient clinics in government hospitals has severely affected the finances of several hospitals, which will likely affect the salaries of doctors, nurses, and the administrative staff of the hospitals. However, the Finance Ministry refused to compensate those hospitals in case of financial losses.
The source tells Mada Masr that hospitals, such as Heliopolis Hospital, 15th of May Hospital, and other hospitals affiliated with the Curative Care Organization and the Specialized Medical Centers division, were generating income for the Health Ministry through revenues from outpatient clinics and surgeries. For this reason, the source explains, reversing the decision to close outpatient clinics and assigning fever and pulmonary hospitals — whose services have always been almost completely free of charge — with COVID-19 cases will alleviate the economic burden on the rest of the government hospitals.
A source in the Higher Education Ministry reiterated the same narrative to Mada Masr, adding that the Qasr al Ainy Hospital, which has been an isolation hospital for faculty members and employees of Cairo University, and the Obour Specialized Hospital, where members of Ain Shams University are isolated, have both been financially harmed due to the COVID-19 crisis. The administrations in both hospitals decided to coordinate with the Cabinet to provide a paid medical service to COVID-19 patients who can pay for their own treatment. Each hospital prepared a preliminary price list, then the price list of the Qasr al-Ainy Hospital was circulated over the past few days to test the waters and assess people’s reactions. A public uproar ensued, after which the Cairo University spokesperson issued a statement denying that the cost of COVID-19 treatment, as per the circulated news, is LE127,000 for a 14-day stay inside a hospital ward or LE103,000 for a 14-day stay in the ICU. But he stated that the French Qasr al Aini Hospital will provide paid healthcare services for COVID-19 patients from several companies and international agencies that officially request it.
The Higher Education Ministry source believes that the prices of Qasr al-Ainy Hospital are quite reasonable when compared to the prices in a few big private hospitals that have taken in COVID-19 patients over the past few days. He added that, as of May 12, Qasr al-Ainy did not admit any COVID-19 cases other than the faculty members and employees of Cairo University. But the hospital is expecting to see a turnout of patients in conjunction with the early phase of turning fever and pulmonary hospitals into quarantine hospitals, because, as the source put it, “not all people will accept the level of medical treatment in fever hospitals.”