OP-ED: The secret to fighting the next wave

The devastating third wave of Covid-19 in Bangladesh thankfully seems to be behind us, and we are all breathing a sigh of relief in going back to our regular lives, at least for now. However, the grim reality of only 9.7% of our population vaccinated, and our nation’s collective failure to mount any meaningful defense against the rise in infections even after three waves of the pandemic, begs the uncomfortable question -- are we well-prepared with the right strategies to prevent and fight a fourth wave that may arrive as early as winter?

Only 5% of Bangladesh’s total population has been fully vaccinated against Covid-19. Total number of people who received all doses prescribed by the vaccination protocol, divided by the total population of the country.

Graveyard of flawed strategies

The nationwide death toll from Covid-19 in Bangladesh crossed the grim threshold of 27,414 as of September 26. Despite adding various adjectives ahead of “lockdown” to signal the seriousness of the government in each turn, we have largely failed to keep people indoors, and therefore to stem the tide of infections. Lockdowns are also highly expensive as a strategy to fight Covid-19. It is akin to chemotherapy in fighting cancer -- due to poor targeting, it shuts down vital societal functions in order to stem the tide of infections.

Many experts have argued that lockdowns are not appropriate for a low-to-middle income and highly populous country such as Bangladesh, where a lot of people work in the informal sector and rely on daily wages to survive. With Dhaka alone having around 1.1 million slum dwellers (as of 2015) living in extremely close quarters and sharing bathrooms, social distancing sounds like a cruel joke.

Most of the lower income communities do not have enough knowledge regarding the virus, often claiming Covid-19 only affects “the rich’’ or does not affect Muslims. Several low-income workers and daily labourers such as factory workers, rickshaw pullers, and CNG drivers have been going to work in high contact jobs to earn a basic living, or have been leaving the capital in masses for their villages due to inability to pay rent.

Widespread use of masks is another strategy that is more cost-effective and can minimize disruptions to lives and livelihoods, but has proven extremely hard to enforce. The gold standard of masking programs, the NORM model developed by Yale University researchers, was successful in getting only 46% of people to wear masks correctly while in public (without the program it was just 13%) (Jason A., 2021).

Top-down directives such as lockdowns, social distancing, and masking requirements have therefore failed to reach the desired levels of adoption to be effective. Why is this so? And what gaps in our strategies so far, if plugged, could generate a greater level of compliance and effectiveness in fighting future waves of infection?

The Achilles’ heel

The problem is that anything that requires compliance also requires consent, especially in the absence of strict enforcement mechanisms. Lockdowns, social distancing, and masking guidelines largely failed because the citizenry was not bought into the process. The secrecy and opacity with which the decisions were taken and communicated, often at the last moment, did not inspire confidence among the populace that their best interests were being considered in these decisions. Furthermore, allowing certain influential stakeholders to continue business-as-usual while restricting movement and rounding up poor people only confirmed those suspicions further.

So, while lockdowns and masking may be essential strategies in our fight against Covid, they were by no means sufficient to achieve results without a correspondingly high level of community engagement and participation in the decision making and execution process. As Professor Dr Liaquat Ali, honorary advisor at Pothikrit Institute of Health Studies, wisely said as early as April: “The authorities should engage the people before announcing a lockdown. Issuing an order without community-level support might backfire.”

A sliver of hope in our backyard

We may not need to look far to find a solution to our woes. Savar upazila, in the outskirts of Dhaka, has achieved an unmatched level of success in curbing Covid-19, compared to Dhaka Metropolitan or other similar industrial hubs.

Despite being home to a significant percentage of the country’s industrial factories and having millions of workers commuting daily from surrounding areas, Savar Upazila has seen less than 100 Covid deaths against a population of 14 lakhs so far, approximately one-sixth the per capita death rate compared to Dhaka metropolitan area. So how did Savar achieve this, that too without additional funds or resources?

The key to the upazila’s success has been a deep engagement with community stakeholders to get buy-in and compliance from people with behaviour change communications and guidelines. Moreover, this was accomplished under highly synchronized coordination among and by local government agencies, and farsighted and proactive leadership from the Savar Upazila Health Complex (UHC) in a moment of crisis.

The Covid response strategies adopted by Savar Upazila Health Complex (UHC) show clear proof that strong local leadership and engagement of all stakeholders in Covid-19 response is an essential ingredient (and unfortunately highly neglected in the rest of the country) to fighting future waves of the pandemic that are sure to hit our shores in the months to come.

A proactive strategy led by local governments

The difference was the proactive approach by the Savar UHC, and the Upazila Health and Family Planning Officer (UHFPO) Dr Shayemul Huda, who jumped into action even before the first Covid case was detected in Bangladesh on March 8, 2020. 

The challenges were formidable -- a severe lack of factual information and knowledge regarding Covid-19 amongst healthcare workers and public, stigma and rumours surrounding the disease, lack of PPEs, severe shortage of hospital staff, and on top of that, the daily influx of garments workers into the area.

The way the UHC dealt with these challenges was by calling on community stakeholders to get engaged where they were best suited to help, and a sincere effort to collaborate and partner instead of direct and enforce. This created a sense of shared ownership and responsibility, and achieved miraculous results at a fraction of the cost of other programs.

Calling on key stakeholders

By working in conjunction with the Union Chairperson and the MPs, Savar UHC utilized local resources by including community leaders, health providers, policy makers, local businessmen, local law enforcement, journalists, religious figures, and volunteers in its Covid-19 response strategy, and deployed each group to their optimal role in tackling the crisis.

In the very early days of the pandemic, the UHC secured support from the Upazilla Chairman who donated a separate ambulance for transporting Covid-19 victims, which allowed non-Covid patients to be transported safely without risking infection. 

Police were engaged in limiting unnecessary movement, contact tracing Covid positive individuals, and ensuring they maintain quarantine and isolation. Journalists were asked to report on case hotspots and undue movement, and also to inform the population on various UHC services made available during the pandemic, including a hotline number that was open 24/7.

Nearly 500 volunteers were recruited and trained for proper burial of Covid victims, at a time when stigma around the disease was causing unfounded fear among families about burial of deceased relatives. Religious leaders such as imams and purohits, who are highly influential in their communities, were contacted and mobilized to raise awareness regarding hygiene protocols, and to eliminate tensions about the risk of virus spreading during prayers. Imams were also used to promote vaccinations once it began in February 2021. 

Using private health providers and reducing the burden on infrastructure

A key challenge facing the UHC was its limited infrastructure to deal with an influx of patients, as many as a third of whom may come prematurely without requiring hospitalization. 

Knowing local pharmacists and Rural Medical Practitioners (RMPs, also known locally as “village doctors”) are trusted as a first-point-of-care by over 70% of Bangladesh’s population, Dr Huda involved more than 2500 RMPs in a rigorous training program to combat and manage Covid-19 at the community level. They were trained to promote mask use and combat misinformation in the community, list high-risk patients among their clients, monitor them for symptoms regularly, and refer patients to the UHC as soon as they develop severe symptoms requiring hospitalization.

Pharmacists and RMPs were trained to not provide unnecessary drugs and antibiotics for Covid-19. RMPs were also trained to measure oxygen saturation and provide clear instructions for home quarantine. Partly as a result of this decentralized intervention, the UHC never faced a shortage of beds or other infrastructure during the three waves so far.

Mitigating the historically uneasy relationship between UHC doctors and RMPs was a challenge that Dr Huda was keenly aware of, but he knew that he needed all hands on deck in this fight, and that he needed to reach and care for people where they are.

In his words: “Rural populations are close to village doctors as they can connect to them easily. These relations can be used to receive actual information from the ground. If village doctors can provide primary care and inform UHC in a systematic way on severe cases it immensely helps to provide timely care to the patients amid this emergency, and can also help the system cope with the pressure.”

Managing infection in factories

In addition to the community, RMPs, and volunteers were also deployed to the garment factories and other industries to triage and refer symptomatic patients. Savar UHC directly liaised with factory owners and the BGMEA to implement sanitation measures, production and distribution of masks, and conduct regular Covid-19 testing at the factory premises, in order to reduce the spread of infections while on-the-job. Awareness campaigns were conducted, pamphlets with guidelines from WHO, IEDCR, DGHS were distributed in pharmacies and factories, and circulated heavily on social media platforms.

Takeaways from the Savar UHC’s Covid-19 model and potential to scale-up

Savar UHC’s Covid-19 response shows clearly how gaining buy-in and cultivating ownership among key stakeholders and communities can increase compliance, reduce caseload and amplify the impact of other directives such as lockdowns and masking instructions. There are several key takeaways from this experience that can help formulate a robust and low-cost prevention and mitigation strategy for future waves of Covid-19.

First, decentralized leadership and management of community engagement is key. It cannot be centrally planned and executed; instead, proactive local officials, preferably from the health cadre, must be in charge of designing and executing the strategies and involving other stakeholders in the process. However, they must also work with guidance, feedback, and support from other government stakeholders, such as the local minister or MP, Upazila Chairman/Committees, and the District Commissioner’s office.

Second, we must recognize and utilize existing assets, and there should be no place for ego or historical divisions. Religious leaders may have opposed other programs in the past -- that does not mean they can’t be an ally in this fight against the biggest public health crisis of our times. RMPs may have many problems and capacity constraints, but they can also be an invaluable asset in reaching communities and managing cases where they are at almost zero cost. Respectful treatment with clear guidelines and asks for each group is absolutely key in securing enthusiastic participation from them.

Thirdly, identifying problems clearly and thinking of solutions creatively is key. It only took a heartfelt appeal on the Savar UHC’s social media to secure over 450 community volunteers for burial and cremation support.

Community engagement might be our last hope

It is an undeniable fact that testing and treatment facilities are primarily clustered in Dhaka city, and we will not be able to set up enough ICU beds, ventilators, funds, manpower and PPE in all parts of the country. We must have also learned from our experience of the tremendous cost of imposing lockdowns, and the difficulty of getting people to wear masks. 

Given these realities, there are few strategies as cost-effective in increasing compliance and preventing community spread of infections as a robust and decentralized community engagement model as implemented in Savar. Not only can it generate buy-in and therefore compliance on existing prevention measures, it can also serve to co-opt new resources (pro-bono human resources, in-kind materials support, etc.) to the fight which would have been impossible to materialize from public coffers. 

All it needs is some proactive leadership, and a willingness to bring the government down to the level of the people, to work hand-in-hand and shoulder-to-shoulder in this historic crisis.

Sadmani Haque, M Tasdik Hasan, Rubayat Khan work for Jeeon Bangladesh Ltd. Sadmani is a research intern, Tasdik is contributing as the research lead & Rubayat is the CEO.