In 2021 as Bangladesh celebrated 50 years of independence, her citizens were struck with the deadliest wave of the Covid-19 pandemic. As the number of deaths per day grew at a rapid pace and crossed 250, there was a palpable fear among the health professionals and aware citizens that the country might face drastic consequences of the disease, like Brazil or India was, at that time. But the worst did not come to pass and the overall death tally due to the disease stagnated at the 30,000 mark—a miraculous tally—if you look at how nations with more advanced health infrastructure suffered from the pandemic. Was it a divine miracle, or a culmination of different factors leading to a positive outcome?
It has to be acknowledged that the fear and panic that were spreading was not unfounded. Bangladesh’s health system bears its legacy from the late British Empire and later the Pakistani period where the primary concern was a different type of communicable disease, namely Acute Watery Diarrhea and its more severe cousin Cholera. Cholera had claimed tens of millions of lives across the subcontinent over the first half of the twentieth century and its menace in the region dates back thousands of years, earning her a place in the pantheon of local gods. The colonial legacy doesn’t stop there though. It can be traced to posts like Civil Surgeon (head of the health hierarchy at the district level who, however, doesn’t do any type of surgery), the preoccupation of Bangladesh’s healthcare workers with being addressed as “sir” or “madam”, having posts like MLSS (member of lower subordinate stuff) to play the role of orderlies in stead of enough medical technicians etc.
Over time, the health system has gained significant experience in treating mild to moderate varieties of pneumonia. But the number of deaths, especially under five mortality rate due to the disease, has remained high in this part of the world. Similar to Covid-19, pneumonia also requires continuous oxygen supply in managing severe cases, sometimes in high concentrations. But, out of the nearly 500 Upazila Health Complexes (UHCs) of the country, the primary health care centers of the government health system, the number of facilities with provision for oxygen supply barely made into double figures in pre-Covid era. Many pneumonia patients had to die over the years despite being hospitalized. After witnessing a similar incident during his internship, the Bangladeshi physician Mohammod Jobayer Chisti invented the use of discarded shampoo bottles as an affordable alternative to CPAP machines—an essential breathing instrument for treating patients with severe pneumonia.
Many people who were affected with Covid-19 required rigorous monitoring during their treatment. So, the availability of ICU (Intensive Care Unit) and HDU (High Dependency Unit) beds became a crucial factor for the survival of numerous people infected by this deadly virus. These specialized care units also require health care personnel who are specifically trained to manage these units, who have ample experience in dealing with dire clinical circumstances. Critical Care Medicine specialists and Anesthesiologists usually in charge of managing them were already few in number. The number of these critical care units in Bangladesh were limited when the pandemic hit the country. There were only 2139 ICU and 717 HDU beds which was already inadequate to cover the medical needs of the country prior to the pandemic. These specialized yet crucial services were available only in 79 government and 129 private hospitals. 38 out of the 64 districts had neither of the facilities available locally. When the Covid-19 pandemic hit the country, the lack of access to these specialized services led to many tragedies in personal, familial and community levels. The loss that we all experienced collectively is profound, unmeasurable; we are all marred by it. Some of us have lost people close to us, family or friends, or a distant relative. The elderly population of the country, who were already vulnerable, often living with comorbidities, was hit the hardest
Even under regular circumstances, Bangladesh hardly produced enough medical grade oxygen to meet her own needs and a substantial import from India was always essential to meet the demand. As the disease spread like wildfire across India killing hundreds of thousands, Indian supply of this essential medical commodity started to dry out as India’s domestic need for it grew exponentially. The oxygen stock of Bangladesh rapidly fell down to dangerously low levels. This acute crisis of oxygen was felt severely by the relatives of the ailing patients. They were desperately searching for oxygen cylinders, and most of these endeavors were ending in failures. But despite all of these, the worst fears did not come true. The United States lost more than a million of her citizens, Brazil and India each lost upwards of half a million. Then what actually saved Bangladeshi people from sharing that gruesome fate in the same proportion?
Whenever the pandemic started spreading out of control, the Government of Bangladesh used the then infamous “lockdown protocol” to great effect to curb the spread; even at the risk of slowing down the economy. During the pandemic, the government realized the lack of essential ICU and HDU units in the country and swiftly made arrangements for an additional 1186 ICU and 695 HDU beds across both the public and private sectors. A few hundred specialists were enrolled in government service under special provision for managing these specialized units. in various government facilities. Plans were made to ensure that every district had access to critical care facilities run by the public sector so that the gravely ill patients could be started on high-end treatment as soon as possible. However, this ambitious plan could not be fulfilled on time.
The relatively low average age of the Bangladeshi population meant the number of people older than fifty who were affected by the disease, and simultaneously had one or more comorbidities such as hypertension, diabetes were few. The presence of these comorbid illnesses meant a poorer prognosis of Covid-19. A disproportionately high number of elderly people had died from the disease (actually trumped the under 40 population by a factor of several) though the vast majority of the affected were from younger generations. This is one reason that explains why countries with relatively more elderly populations suffered a greater blow in the pandemic.
By the time the deadliest variants of the Covid-19 virus started spreading in Bangladesh, the government had acquired substantial amounts of Covid-19 vaccines. The vaccines were not procured from a single source–helping us avoid the geopolitical quagmire it had become for several other nations. Bangladesh was well experienced in distribution of vaccines to her population because of its robust Expanded Programme on Immunization (EPI) infrastructure. This ensured a fast paced roll out of these vaccines through an experienced and efficient framework which was already in place, first prioritizing the most vulnerable portions of the society. Domestically it was also possible to ramp up the production of medical grade oxygen substantially to be able to hold out long enough till the crisis in India had subsided.
Bangladesh may have unexpectedly achieved success in the Covid-19 pandemic, however, ignoring the problems plaguing its health infrastructure is unwise. The healthcare system acutely suffers from poor planning and short-sightedness which is also applicable for almost all sectors of the country. One can surely see how overworked a doctor in any government setting is, treating hundreds of patients each and every day; a task made even harder by lack of appropriate facilities to help in the process. But what generally goes unnoticed is the exceptionally low number of nurses and other support staff which hampers the treatment of admitted patients. A group of two or three nurses often needs to take care of over a hundred patients during an eight hour shift which is bound to impede the level of service. The doctor to patient ratio is far from achieving the WHO standards, but the doctor to nurse ratio is even more abysmal (2.5:1 compared to WHO recommended 1:3).
In the national budgetary planning, the health sector has faced continuous negligence in receiving public funds. Corruption and inefficient management of these resources mean that most government run facilities lack proper infrastructure, machinery and even timely supply of adequate amounts of needed medications. News of public facilities poorly supplied with essential medical equipments like X-ray, ECG, CT or MRI machines surface every now and then. Even where these machines are functioning, often there is none to operate them. This results not only in monetary loss for the patients but also causes extreme discomfort, requiring them to move from the hospital to a private diagnostic center and back.
The lack of intersectoral communication and coordination between different branches of the government has resulted in the inability of the health sector to prevent disease outbreaks even if it had been identified at or near the point of origin. This is best exemplified by the ongoing dengue epidemic breaking all previous records where the health sector had expressed concerns about a possible massive outbreak as far back as March and April of this year after reports suggesting extensive numbers of larvae being found in various random samples taken in areas belonging to both city corporations of the Dhaka city in pre-monsoon routine tests surfaced. But local authorities only kicked into gear in late July. By that time the city was already done acting as a national epicenter, spreading the dengue virus to every district of the country.
If we just sit still and keep glorifying ourselves for what we achieved in the last pandemic, the next one might prove a devastating one for us. And in this age of international communication it is always just around the corner, lurking behind the shadows biding its time to come forward.
