What worked and what didn’t in our handling of the pandemic
Bangladesh has fared much better in managing Covid-19 than many of us had feared we would. The battle with new variants and breakthrough cases will continue till we reach a critical mass in vaccination. But for now, as we recover from the third wave and the third lockdown in the last 19 months, a retrospective study to analyze the actions taken to avoid an anticipated humanitarian and economic disaster will help us recognize our strengths.
These observations were first delivered as a talk for a Brown University panel on “Covid 19 in South Asia,” together with Barkha Dutt representing India and Dr P Saravanamuttu from Sri Lanka. Till date, 97.2% of the total 1.54 million confirmed Covid cases have recovered. Our death rate continues to be 1.76%. The actual number of cases is undoubtedly higher, not just because there wasn’t enough testing but also because of the undetected asymptomatic cases all around us.
So, that means our death rate was probably even lower? Maybe, maybe not -- deaths from Covid like symptoms were reported from many districts -- for instance in Satkhira at one point there were 446 deaths from Covidlike symptoms but only 80 were confirmed Covid cases.
It would have been ideal to keep a log of deaths from suspected Covid, confirmed Covid, long-Covid, and postCovid complications for future reference. Interestingly, despite all these arguments, in 2020 Bangladesh’s total death rate was 5.541 which means, for every thousand people 5.5 people died; the number was 5.545 in 2019. Compared to the neighbouring countries, Bangladesh’s numbers are impressive.
What worked? Having worked in a2i for all of 2020, I am a witness to the fact that decisions concerning Covid are based on studying strategies of countries successfully controlling their outbreak, analyzing people movement, smart use of available resources, and taking scientific opinions from experts.
It was the concerted effort by the government, private and development sector that helped bend the curve every time. I am laying down some of the actions taken for the audience to come to their own conclusion.
The three waves and three lockdowns
There is no dispute that the lockdowns broke the chain of infection. The rules set were standardized with other countries -- banning all public gatherings; shutting down educational institutes, offices, and factories, restricting intra/inter district transports movement, suspending flights, etc. During the first wave, triggered by imported cases the test positivity rate was 23% on an average, and general lockdown was lifted only when hot spot mapping was established to ensure granular restrictions.
A relatively good spell of three months broke with the arrival of the beta variant in March 2020, when again the test positivity rate was around 18%, and a second lockdown was imposed. Soon after, the third hard lockdown was enforced due to the rapid spread with the Delta variant in the border districts. The goal was to save Dhaka from 15 red zone districts in Rajshahi, Khulna and Rangpur division. 465,183 cases were recorded in only 42 days of the third lockdown, whereas it took six months to get to 313,000 cases in 2020.
These numbers and the 28-31% test positivity correspond with a Yale University report that in an unmitigated environment one person infected with Delta can infect 3.5 to 4 other persons, whereas a person infected with the original Sars-Cov2 would spread to 2.5 persons.
Capacity increase in health care services
We currently have 800 testing centers all over the country compared to only five in Dhaka for the entire nation back in April 2020. RT-PCR accounts for 90% of all the confirmatory tests. 86 out of the total 140 RT-PCR testing centers are privately owned. The government provides free rapid antigen tests from 545 and gene-expert testing from 51 centers. RT-PCR costs Tk100 in government centers and is free for the marginalized, and at private facilities it costs Tk3000-4500. The price of imported RT-PCR test kits came down to Tk800 per kit from Tk3000 last year.
Till date over 9.4 million tests were performed out of which 74% were done in government facilities. The testing capacity is believed to be 55,000 a day now, and at the very beginning of the pandemic, IEDCR was doing 33 tests a day.
In April 2020 we only had nine dedicated Covid hospitals. Now, 100 government and 39 private hospitals all over the country are serving Covid-19 patients. Only 69 out of 218 government ICU beds were functioning in June 2020, when the total number nationally stood at 381. By September 2021, there are almost 17,000 general beds, 1321 ICU, and 856 HDU beds dedicated to treating Covid patients. Since Dhaka is the most densely populated, 54% of all cases and 43% of all deaths are reported in Dhaka, which explains why 44% of all the hospitals are also in Dhaka.
The need for high flow oxygen for Covid was identified early on and a strategy was taken in June 2020 to install liquid oxygen tanks at all the Covid dedicated hospitals to ensure uninterrupted supply through the central pipelines. Hospitals increased capacities to deliver oxygen from central oxygen tanks, oxygen cylinders, and oxygen concentrators. The shortage of PPE was fulfilled by ramping up local production and distribution by public and private initiatives.
Health is an out-of-pocket expense and in private hospitals treatment of Covid patients can cost anywhere between Tk37,000 to Tk68,500 a day, depending on the care. This expense and more beds being available in government hospitals might explain the higher number of deaths (84% of total) reported from the government hospitals.
More recognition should be given to our pharmaceutical industry. 98% of all the domestic medicinal needs are fulfilled by this industry. Except for Tocilizumab (Actemra), the immunomodulator used to reduce the cytokine storm, all other drugs to manage the Covid-19 infection are manufactured locally. They have also extended their facilities to help the government store the vaccines.
Government stimulus packages
Our prime minister announced a total of Tk131,000 crore stimulus in the last 19 months. The first stimulus package of Tk72,750 crore was announced in April 2020, and a total of 121,353 crore stimulus was announced by November 2020. This was 4.3% of our GDP and 70% of this was disbursed by April 2021. Last stimulus of 3,200 crore was announced in July 2021.
The aim was to increase public expenditure through employment generation, focus on agriculture production, provide safety stimulus for industries by providing low interest rate credit facilities, and widen social safety coverage to protect the poor working in the informal sector with food support, direct cash transfer, and housing facilities.
The international community and the NGO sector USA and USAID mobilized $96 million for Bangladesh to battle the pandemic; the UK, the World Bank, and some other nations’ donations are also well received. BRAC leads the pack of the local NGOs and has supported 100,000 with cash subsidy; their field force of 50,000 women healthcare workers were engaged in educating 4.7 million people with Covid preventive information. They also contribute in all aspects of public health related studies for Bangladesh.
Corporate houses, private citizens, and humanitarian organizations stepped up to do their part for the community. Local elected representatives and local administrations ensured last mile distribution of relief materials and rations including food packages. We lost 106 law enforcement officers, and 186 doctors to Covid-19 in the line of duty as frontliners. 100 MPs -- almost a third of the House -- contracted Covid, and sadly four of them succumbed.
We have 110 million mobile phone users, 107 million have internet access and 40% of mobile users have smartphones. The government and the private sector leveraged ICT as the great enabler to survive the lockdowns through e-commerce, e-health, e-banking, e-governance, and e-education. Out of many, the most prominent services by ICT during this pandemic are the vaccine registration “Surokkha” portal, Corona Helpline 333, Virtual Court System (MyCourt), telehealth services, and digital classrooms.
The business continuity plan of ICT approved by the prime minister to ensure an uninterrupted network facilitated online office, grocery shopping, food order and delivery apps, mobile banking, online pharmacy, bill payments, telemedicine, and entertainment.
Vaccine procurement and the vaccine program
Bangladesh ensured citizens’ safety by approving vaccines that received emergency use authorization by the FDA, EU, and WHO, and targets to vaccinate 117,856,000 people (80% of the population) for free. The country was applauded for being the first in the region to make a vaccine deal as early as November 2020 with Serum Institute of India. Unfortunately, after India halted vaccine exports, a crisis period extended from April to June, despite a successful beginning in February. The Covax initiative promised us 60 million vaccines in phases, and under this the US donated 6.5 million Pfizer and 5.5 million Moderna, Japan donated over three million AstraZeneca, and China donated 3.4 million Sinopharm vaccines.
Bangladesh is buying the majority of the vaccines from Sinopharm and proposing to package them locally. The vaccination program was made easy through the “Surokkha” app, which provides the vaccine certificate along with registration. The government’s strategy to vaccinate migrant workers going to Saudi Arabia and Kuwait with Pfizer and Moderna to avoid unnecessary, expensive quarantine is laudable. As schools reopen, the government plans to vaccinate the 12-18 age group with Pfizer and Moderna. Till date 12% of the target population is fully vaccinated and 18% is partially vaccinated.
What else may have worked?
●The government’s policy of “no mask, no service” and continuous reinforcement of mask usage by the auto generated voice message at every phone call
●Bangladesh’s successful EPI program the last four decades was the foundation for the successful Covid-19 vaccination program. During the six-day mass vaccination program in August and September, over 50 lac people were fully vaccinated
●Homogeneity of the population made communication easy where community and religious leaders participated in spreading awareness
●Highest remittance of $19.8 billion and a positive GDP growth of 3.5% was recorded in 2020
●A study reinforced healthcare experts’ claim that 60-70% people may already have Covid-19 antibodies
●A large segment of the youth population might be a contributing factor as well. The productive utilization of this generation will be crucial for nation building
●Protecting the one million Rohingya population
●The gains in some of the indicators that took decades to establish took a blow due to the pandemic.
●There are 24.5 million “new poor” in Bangladesh in 2021
●High unemployment rate among women continues. One million garment workers lost their jobs last year
●Research on 65,000 women and children in 53 districts showed that 30% of these people became victims of domestic violence for the first time during the pandemic
●Child marriage has increased by manifolds due to school closure, unemployment, and rising debt among the poor
●8,000 enlisted sex workers have become homeless
●Education loss due to school closure for 18 months. 15,000 private kindergarten schools have shut down
●40% of children suffered from malnutrition during this time due to a drop in parents’ income
●Stigma related to Covid -- although much less than at the beginning -- is still there
Wins and what’s next
The biggest win is that each and every person we lost to Covid was given a dignified burial by our voluntary humanitarian organizations. We did not have any mass burial. The government, together with the private and development sectors, focused on ensuring food safety, continued economic activities to reduce unemployment, saved the industries contributing to the GDP, and broke the chain of infection to avoid horrors like in India.
When I had the opportunity to show this data to an international community, the expert moderator observed that the numbers in Bangladesh and the recoveries from the outbreaks till date cannot be attributed to vaccinations as is done in Israel or the UK, but it is simply because we had good leadership, strategy, and a determined conviction to come out of it stronger.
Hope this data helps in reinforcing our trust in our own abilities, and yes let’s keep the masks on.
Dr Maliha Mannan Ahmed is the Founder and Executive Director of Organikare. She has an MBBS, MBA, and a Master’s in Health Care Leadership.