Healthcare During Outbreak: Vulnerability EXPOSED

"Today we are unable to say what we had been saying until now. We have found three patients..."

These were the words of the then IEDCR director Prof Meerjady Sabrina Flora on March 8 after the first detection of coronavirus cases in Bangladesh, which changed everything, most probably forever.

Since then, Covid-19 infections multiplied, the number of deaths increased with every passing day and more importantly, the pandemic laid bare the vulnerability of the country's healthcare system.

Uncertainty, lax coordination, disparity in providing health services, corruption and a dearth of logistics and manpower spoke volumes of a weak health sector and its weaker institutions in tackling an unprecedented health emergency that marked the year 2020.

"The main feature of the Covid-19 emergency is that it has exposed the faulty healthcare system of the country," Prof Ridwanur Rahman, a medicine and infectious disease specialist, told The Daily Star.

First detected in the Chinese city of Wuhan late in December 2019, Covid-19 has so far claimed around 1.8 million lives globally, including 7,531 in Bangladesh.

A year after its emergence, the pandemic, which has devastated lives and livelihoods across the globe and forced countries to pour billions of dollars, is still going strong.

Very recently, a new strain of the novel coronavirus believed to be "more transmissible" has emerged in the United Kingdom, forcing European countries to shut down borders and many other countries to suspend air communications with the UK.

When the pandemic hit the country in March, a widespread shortage of personal protective equipment (PPE) and substandard PPE came to light.

This caused loss of confidence among frontline healthcare professionals. Besides, around a dozen doctors were issued show-cause notices for writing about the substandard PPEs on their social media accounts.

"At the beginning, [the government] tried to keep the issue of fake [substandard] PPE secret…. there was no step to address it," Prof Dr Ehteshamul Haque Chowdhury Dulal, general secretary of Bangladesh Medical Association, told The Daily Star.

He said 112 doctors have died of coronavirus, as of December 28.

"But the doctors and other healthcare professionals did not get due recognition despite their valiant efforts in fighting the pandemic."

He said the casualty among the doctors was more due to the lack of a triage system in the hospitals for systematic prioritising of patients' treatment according to how urgently they need care.

"The entire Covid-19 planning was driven by the bureaucrats and the chaos is mainly for that reason," the BMA general secretary said.

He also lamented that family members of only one deceased doctor has been compensated so far.

INADEQUATE TESTING AND SCAMS

For a long time, since the Chinese virus started shaking the world, the government kept the testing facility limited to the IEDCR lab only. It was against the "test, test and test" policy suggested by the World Health Organisation (WHO).

Hospitals also started refusing to treat even general patients without a Covid-19 negative certificate. It led to untold sufferings of people seeking medical attention and hundreds of such patients died without getting treatment.

Sixty-three-old Monowara Begum was one such patient who died in an ambulance on June 2 after six hospitals in Sylhet refused to treat her fearing she had Covid-19. Her tragic death made headlines.

Despite executive orders to treat each and every patient and a June 15 High Court ruling that said such deaths will be termed as "deaths due to negligence", the situation did not change until testing was expanded across the country.

On March 29, the Directorate General of Health Services (DGHS) announced the expansion of Covid-19 facilities and now there are 114 RT-PCR, 24 gene-expert, and 29 rapid antigen-based test labs across the country.

When the number of daily tests was rising, the health ministry surprisingly imposed fees for Covid-19 tests from June 29.

Quoting experts, the Lancet journal wrote on August 29 that the Bangladesh government's approach to testing and surveillance, including charging patients a fee, is hampering the Covid-19 response.

"Since the beginning, the government's strategy against Covid-19 was suicidal, Prof Ridwanur said. "From screening at the ports, and quarantine to testing and contact tracing -- all were in name only."

The number of daily tests has remained stagnant at around 12,000 despite all the labs having a combined capacity to run more than 30,000 tests a day, he added.

Then there were allegations of fake tests with around 40,000 fake Covid-19 certificates given out by Regent Hospitals Ltd and the JKG Ltd in early July.

Even after months went by, the government is yet to set up much-needed central oxygen supply systems in most district hospitals despite repeated call from the National Technical Committee (NTAC) on Covid-19.

"If there were uninterrupted oxygen supplies in hospitals, many lives could have been saved," Prof Nazrul Islam, member of the NTAC, told The Daily Star.

Besides, uneven distribution of ICUs across the country remained a major concern in treating critical and elderly Covid-19 patients. 

Parallel to lax management of public hospitals, the government had little control over private hospitals in case of treatment expenditure.

While experts see the government's failure from different aspects, Prof Flora, now additional director general (Planning) of the DGHS, disagreed.

"The Covid-19 was an unknown challenge for the entire world. We had limitations. Despite this, the transmission had never spread widely. From nothing, we have now 167 Covid-19 testing labs. These are our big successes," Prof Flora told The Daily Star on Monday.

THE COORDINATION GAP

The government's response to the coronavirus outbreak has been plagued by wrong decisions, delayed actions, and muddled thinking from the very first day even though it got three months' time to take preparation.

Since the beginning, the health minister and his officials repeatedly said they were fully prepared to handle Covid-19 transmission, which, according to the experts, gave a "wrong message to the people."

Health Minister Zahid Maleque on August 15 said the Covid-19 virus will leave the country on its own. "Whether the vaccine comes or not, coronavirus will leave the country."

Before this, Minister of Road Transport and Bridges Obaidul Quader had gone as far as to say: "We are stronger than the corona."

While these comments went viral on mainstream and social media and drew flak, a clear lack of coordination among government organisations everywhere also surfaced every day.

The authorities lagged behind in taking decisions like closing airports, sending returning expatriate workers to compulsory quarantine, and imposing a total shutdown.

Internal feuds among different government entities caused delays for the authorities in preparing the emergency response plan on Covid-19, say experts.

Initially, the IEDCR, the government's disease control agency, was dealing with the pandemic, but then a feud between the high-ups of IEDCR and DGHS delayed the finalisation of the emergency response plan.

Then came the quarantine fiasco. More than two lakh people entered Bangladesh between March and August when the virus was spreading across the world, prompting countries to shut their borders.

But as the Bangladeshi expatriates started coming in, the government allowed them to go home without putting them into mandatory quarantine.

After many countries resumed air communications, hundreds of thousands of expatriate workers fell into a dire situation having no testing certification support for them.

On March 23, the government announced a shutdown effective from March 26, but kept public transport running. As a result, tens of thousands of people left Dhaka having been exposed to the virus.

The government then extended the shutdown in phases, which had a substantial impact on the country's economy.

For the first few months, cases were restricted to Dhaka and cities like Narayanganj and Gazipur. But there was no mechanism to control the exodus of the people leaving Dhaka city centring on Eid-ul-Azha in July-August.

This, according to experts, resulted in the spread of the virus across the country. Then came the influx of hundreds of thousands of garment workers returning to Dhaka with no safety guidelines followed.

"When China was struggling, the IEDCR said, 'we are prepared'. But they were not supposed to say it as a research organisation. In the middle [of 2020], the government got better prepared following pressure from the media and others," Dr Ehteshamul said.

Prof Ridwanur said different organisations of the government did not work as a team while in Prof Flora's view, "It was a new experience for them. But now they are well-prepared."

Asked about any issue the government failed to address, Prof Flora said, "We have not been able to engage the community properly."

THE CORRUPTION AND THE STEPS

In response to widespread criticism over corruption, the government removed some top officials from DGHS, including its director general Prof Dr Abul Kalam Azad.

"Removal of the DG was only an eyewash; no step was taken against others involved. Corruption involving hundreds of crores is not possible for the directorate only. We have seen the then secretary promoted," Dr Ehteshamul said, adding, "The doctors have been kept under pressure on the other hand."

The Covid-19 emergency has unfolded how futile the Infectious Disease Prevention and Control Act 2018 is. The act gave the lead role to the DGHS boss; in reality, its exercise was impossible due to the existing administrative practice of the government.

Dr Abdul Hamid, a professor of health economics at Dhaka University told this correspondent, "We never analyse the root cause when the state takes steps against anything… Apparently we can see the same this time. That Sabrina, this Shahed -- no one is any de-linked person. They have forward and backward links. If we cannot find those links, we cannot be successful in eradicating corruption."

In addition to the Tk 798 crore Covid-19-related expense fund, the health ministry has Tk 100 crore for Covid-19 related expenses in Covid-19 hospitals in Dhaka and across the country.

In FY2020-21, the government has a block allocation for the health sector worth Tk 10,000 crore. 

Besides, there is $500 million pledge from the World Bank, for which a direct purchase plan is awaiting Ecnec approval. It will be used mainly for the cost of Covid-19 vaccination.