Cover Photo: Reuters
A few days ago, I read a report on The Telegraph that discusses how the coronavirus has exposed deep societal divides in Bangladesh. The interviewees in the report talked about non-compliance with lockdowns, community-led approach and the country’s fragile health system. These are all genuine concerns and thoughts. I wanted to add a few of my own to contextualise how Bangladesh ended up as (largely) under-prepared to handle the recent exponential growth in infections despite shutdowns. As of yesterday, the total number of confirmed cases is 84,349. I firmly believe science cannot be implemented effectively by ignoring the deeply entrenched politics in governments and democracies — and therefore, it’s always worth backtracking and understanding it to avoid missteps in future.
Early into lockdown, the country spent more than necessary time fixating on health vs. economy debate, which led us to lose time in determining how we can do both safely. It also reduced public engagement on safety measures because the national narrative over-indexed on economic loss.
Subsequently, when Bangladesh could have been getting private and community hospitals ramped up to widen COVID-19 treatment, there was confusion on whether, in fact, it will hit us as badly. This delayed approving more test facilities, import or local production of testing kits and setting up ICUs, especially in rural areas.
Testing protocol was heavily reliant on technology and calling hotlines, disproportionately leaving out the poor and women. Despite 3G networks covering 93% of Bangladesh’s population, internet uptake is less than 25%. Thirty percent still do not have a government approved identity.
There were few legal safeguards against eviction, job losses or getting turned away from hospitals (i, ii), culminating into increased stigma and under-reporting of symptoms. Landlords, in fear of contracting the virus themselves or losing tenants by spreading it in their buildings, also evicted doctors and lab technicians working at COVID-19 hospitals (and their families). This strained the relationship between the State, medical bodies and the public.
Only a few COVID “specialised” hospitals meant the rest did not know what to do nor had sufficient protective gear, thereby began to ask for “NO COVID-19″ certificates to admit non-COVID patients. At the time, a handful of labs were permitted to carry RT-PCR tests and results typically took 3-7 days to come. As a result, patients, irrespective of condition, hid symptoms to get treated. It was not until an attending doctor or nurse reported feeling ill that the hospitals would discover that a patient is COVID-19 positive. By then, at least 10-12 staff, including doctors, would have come in contact with the patient and many tested positive. Hospitals were quickly losing their workforce.
The lockdown was loosely implemented and poorly communicated to migrant workers, especially in the readymade garments (RMG) sector. This exacerbated distrust in the national response and further affected capabilities in health facilities. The response strategy, being centrally managed, disempowered districts from acting early on, although many reported that they were beginning to see spikes in their constituents.
This loose implementation was predominantly the product of a perceived lower number of confirmed cases than anticipated and emerging data reinforcing the hypothesis that unemployment and starvation as more imminent challenges than containing the virus.
As case numbers increased, the country fumbled on testing, treatment and welfare distribution. Existing problems, e.g targeting, stealing, not knowing what to do and misinformation became bigger during rapid scaling. Instead of refurbishing old systems, new ones got deployed, further delaying actions.
Unsurprisingly, people lost jobs, were hungry and pissed. 50 days into the lockdown, it was evident there were too many delays and the onus of safety and health fell on individuals. A new, misguided (based on partial data) narrative emerged: if lockdowns only delay the worse, maybe they don’t work after all.
And so, here we are today. The recently announced budget for FY20-21 indicates allocation for health has only marginally increased while that for social protection has significantly increased. Both have fallen short of expectations. There continues to be exponential growth in COVID-19 infections and deaths. Very little tangible improvement on government public health infrastructure is observed. The country approaches record budget deficit in recent history.
Bangladesh has a thriving incredible NGO sector and community health worker networks. Together, we beat cholera, smallpox, tuberculosis and polio. But much of this needs (and has historically been done) strong public health infrastructure that cannot be achieved only by doubling down on grassroots volunteer groups or communities coming together. This means government capacity must be built.
National budgets should reflect on gaps. Donors need to spend on public infrastructure. Accurate data needs to be reported. We might get lucky this time, but what happens next time, or the one after? We cannot get to the finish line if we are not willing to do the difficult work of investing in and building the country’s capacity. In a democracy, we should not relieve government of responsibility and accountability.