by AM Zakir Hussain | Published: 00:00, Aug 08,2020
WE LOVE catch words and punch lines. They excite our imagination and stir thoughts. Some such phrases are the ‘new normal’ that is in store for us and ‘a complete overhaul of the health care system.’
Myth of ‘new normal’
Will we keep wearing masks for the rest of our life or for years even after the COVID-19 disappears or when the graph based on daily or weekly or monthly cases of COVID-19 infection falls to a negligible level? Or will we have to practise for the rest of our life a less heroic measure like sneezing into the sleeves. Does the new normal mean that we continue washing our hands every 30 minutes for 20 seconds for the rest of our life? Or we will continue distancing socially, by six feet or more, even in religious congregations or in social events? Will we continue meeting and running the court of law virtually or attend office twice or three times a week? Will we continue with trading online? The advice should hinge on epidemiological facts.
What is the lesson we learnt from the pandemic flue that devastated the world in 1918–1920? Fifty million people reportedly died of the disease. Some sources claim that the figure was double and some claim that it was a third. This figure has to be seen against the total world population of 1.8 billion that time — at 50 million, about 3 per cent of the world population was wiped out. What happened after 1920? Did people change their way of life? The virus H1N1 that caused the 1918-1920 pandemic still exists. Have we adhered to the same way of life since 1920?
Epidemiological lesson that might shape life
EVERY disease-causing agent or pathogen tries to develop a co-existing or commensal relationship with its host. It learns that destroying or killing the host means ending its own life as well. So with time, pathogens become less harmful and hosts become more tolerant to the pathogens. The H1N1 influenza virus is such an example. The same virus which killed 50 million people now is a disease that kills only immunity-compromised people, usually above 65 years of age, while for others it is only a mild flu. Incidentally, H1N1 possesses a remarkable finesse to mutate itself within the same year, but still it is much less deleterious. Will it be incorrect if the same is assumed for SARS-CoV-2? After all, several of the coronaviruses have already disappeared, eg B814 and even SARS-CoV-1 since 2004, just after two years. So, it is too early to predict a ‘new normal’ life. In fact, we believe that people forget their days of trial and tribulation and begin with their known and familiar ways of life when things become close to normalisation. Changing ways of life that is unfamiliar and discomforting frighten people. Nature teaches living things to go back to square one, not only in case of humans but even in animals and plants. We do not see animals with new a way or life or any new life pattern in birds or plants. One thing does not change into another unless there is a serious question of survival or pressure of natural selection. Humans have come a long way to be under any pressure which it cannot surmount or be compelled to adjust itself naturally to satisfy the needs of natural selection.
Complete overhauling of health services
IN THE light of the crimes committed by outsiders with blessing from some ever-unidentified dark forces and by some inside managers, some of whom are ignorant of their own laws, business people stroked the iron as it was hot. Some pundits who never worked in the public health sector suggest an overhaul of the whole sector without any idea how things work at the top and what is at the bottom. We have not really heard as to what should be the extent, type, area and nature of such overhaul. What we can make out from what they say is that we need to change the vehicle since it met repeated accidents. Would not it sound more pragmatic if we rather change drivers only? After all, there has already been a system in place which has worked albeit with some complaints about its quality, for which, weaknesses in some system components, never addressed, is actually responsible — the absence of adequate human resources and adequate healthcare financing. The same people boast of an exemplary system of health care in Bangladesh. So what happened all of a sudden that we want to throw it away, tear it apart and install something that we do not even imagine. While the fault is with the people who work in the system, experts want to throw the bath-tub with the baby in it.
We need to realise that systems develop based on years of experience and experiments. Some systems elements develop and take their place automatically as a natural corollary. Changes in them should also, therefore, occur based on experience and experiments, some of which will, of course, auto-adjust. What we may think about is bringing in some modifications or making upgrade in some terms of reference of the system drivers or change them who are at the helm of management to suit the existing or modified terms of references. This is some small change in different elements of the system which may include financing and financial management, personnel management and logistics management. Questions have, however, been raised time and again about the performance of the people who handled the system elements. Either they would need further capacity-building or they need to be changed if a failure in transparency is the issue.
One overhaul that has been long overdue though is the separation of clinical and diagnostic care from public health. A public health expert will not be able to conduct a surgery; similarly, a clinician will not be able to manage public health. The faster we realise this, the better. Clinicians will be able to manage hospital and diagnostic care and relevant procurement; but they will not be able to contain epidemics, under-nutrition, health communications, personnel management, public health planning and budgeting and alternative financing modalities etc.
Weighing of advices
Ideas, suggestions and dreams of people who call themselves expert that do the rounds are highly likely to be dangerously misleading. Clinical expertise and public health are different. Some people even do not understand that their realms. People talk about epidemiology without knowing epidemiological principles. Epidemiology is a pure science of probability that determines the association of factors as cause and effect. The discipline of public health also, similarly, needs theoretical and practical knowledge and experiences in public health. People may be masters in their discipline but everybody cannot be a master of epidemiology or public health. Advice given by people, of other disciplines, on public health or epidemiology should, therefore, be taken with a grain of salt.
Myth of increased daily test
There is a general perception that the more the tests, the more the number of cases identified. Proportionately speaking, this is not entirely true. Observers have noticed that when the criteria for COVID-19 testing were restricted to cases suffering from four noticeable clinical features, the number of tests decline while the test result rate became higher and the identified cases were fewer. If the number of tests is increased, test positivity will be lower as more non-COVID-19 cases will be included for testing. So an increase in the cases will be marginal and not proportionate to the number of tests. This will reduce test efficiency and as money will be spent unnecessarily on non-COVID-19 cases. The tests conducted now do not tell us about the number or percentage of infection any way, but they show only a falling or rising trend, for which death counts, tested or clinically suggestive, should be a better approach. We need to do random sampling and run antibody tests which will tell us the percentage of infection at the time of test and the percentage of people who recovered. We do not have any information on this in Bangladesh as yet.
AM Zakir Hussain is a former director, Primary Health Care and Disease Control, former director of IEDCR, DGHS, former regional adviser of SEARO, WHO , former staff consultant, Asian Development Bank, Bangladesh. and Working Group member of Bangladesh Health Watch (BHW)