Righting wrongs of COVID-19 estimation

AN OPINION is doing the round as to what should be the number of the tests to be done in Bangladesh with regard to COVID-19. The figure that we hear and read quite loudly and clearly is 20,000. But the question is why 20,000 and why not 19,000 or why not 21,000? Do we need any estimation for developing a strategy to prevent transmission?

For prevention, we need to know how a disease is transmitted and simply let people know of it so that they refrain from traversing the avenues which pave the way for transmission. This is what we know more or less. Epidemiologists learn in their basic course that for the prevention of the transmission of a disease, one does not need to identify the causative organism although it is all the more better for various reasons. It is, in fact, sufficient to know what is the vehicle or vector of transmission, which could be biological, physical, mechanical or environmental, singly or in combination. In this regard, how cholera was controlled in London based on the findings of John Snow, the anaesthetist of Queen Mary, on the water distribution system in the city of London in 1854, is cited as a classical epidemiological example. The cholera vibrio itself was isolated 30 years later in 1884 by Robert Koch.

For prevention, we do not need to know how many people have been infected and who they are. For prevention, barriers are created in the avenues of transmission, when we know about them. This should halt transmission. Prevention should largely be population-based action. But to sensitise people to an effective and efficient behaviour- and practice-based action for prevention, we need to develop a supportive and conducive attitude and belief among people. There are specific time-tested techniques to change people’s mind first. Preventive measures may be better fitted if the nature of a disease-causing agent and the disease itself are understood well. This is especially important if the cause is a virus and more so, if it changes its physical and genetic formations and structures fast, which is a reality in case of an RNA virus.

What estimates should we need to measure the profile of COVID-19? First of all, what should be the aim of making COVID-19-relevant estimations? Then we need to decide what the bits of information are that we need to make estimations? The aim obviously should be the prevention and control of the infection, ie COVID-19. Based on the aim, some bits of baseline information should be in order. They may be on the expanse of the problem, for example, to fit responses, ie we plan and gather resources accordingly by type and volume — match for match.

There may be several other aims of making estimations. The expanse of a disease may be gauged by the number of the people who have been infected, as is obvious; this should include all people irrespective of the type and degree of signs and symptoms that they have been inflicted with or irrespective of any other characteristics. For the answer to the question ‘how many’, we need to test everyone, specific to the location in question, eg everyone in a village, in an upazila, in a ward or city or the whole country. Some location-wise answers may be quite challenging while some would be improbable for various reasons, eg risk, time constraint and limitation of fund. For COVID-19, we cannot get the estimate of ‘how many’ in the country because of these constraints.

The second question will be: who are the people that have been infected? This is, in fact, a mirror image of the question ‘how many’ as if we know ‘who’ we would know ‘how many’ by simply counting the who’s. We need the answer to the question of ‘who’ to control transmission effectively through, for example, the isolation of the people who have been infected. But as may be understood, an answer to this question is as improbable as ‘how many’ as this would also require that everyone in a given location should be tested. A closer strategy may be based on the knowledge of who is suspected to have been infected. This also is as formidable a question as the first two. Because if we do not know all the who’s that are infected, we would not know who to suspect as infected through contact with the people who have been infected.

In the given context, the next best alternative is to test as many people as possible, which for the sake of efficiency, should begin with those who are evidently ill from the disease and their contacts. While the ailing will be easy to identify, the identification of their contacts will be quite complex contextually. This analysis takes us to the realisation that it will be impossible to find out all those people who are the risk of transmission of the disease. This is also complex because many infected with COVID-19 will not show any clinical features or will exhibit mild features for any reckoning. This is a pointer to the fact that the route of finding out who are at potential danger of transmitting the infection is to test as many people as possible irrespective of whether they exhibit symptoms or not. But as those who show signs and symptoms are more potent in the transmission and the more serious the signs and the symptoms, the more is the risk of transmission, it is imperative that we should identify such people to begin with and if the situation permits we expand our net of identification as much as possible, without any magic number.

The contacts, to be clear, should mean the people who mingled with the identified cases in the neighbourhood and the people who the cases mixed with in any other places. Clearly, one cannot give any rule of thumb figure for estimation here because it would be so variable from case to case. Also those who have greater potential of mingling all around because of their potency to move around are the ones who are without any post-infection symptoms or complications.

 

Pragmatic alternative

ALTHOUGH the total number or the identity of the infected may not be a pragmatic consideration, the expanse of any disease may be estimated in the form of rates, which will tell us ‘how many’ but without identifying ‘who’ beyond those who have been examined. This will not help in preventing or controlling the disease very efficiently, but will underscore the effect of the preventive and the control measures undertaken. This will also help in identifying at least those who are considerably inflicted by the disease and will help at least to control the spread of the disease from them. For this an, epidemiological survey will have to be done through a random sampling process. Sampling process decides what will be the sample size for an analytic study or a survey. In a survey, the bigger the sample size, the better should be the accuracy of the estimate. Some other parameters also are adopted to ensure better accuracy, eg the limit of accuracy sought, the correction terms to be used for the weaknesses which are due to the sampling type and process. Statistically speaking, for 95 per cent accuracy, when the population size is more than 100,000 to take the sample from, and when the expected incidence or prevalence is taken to be 50 per cent in case it is unknown, the sample size would be 384,  the highest for any location. If the locations are districts, the required sample size would be 24,576 from the 64 districts of the country. But this will not be based on the COVID-19 suspected cases alone, which however, would include them. The other information that this type of survey provides is what percentage is silently infected and what percentage is not infected.

The current survey gives us the result of the tests done on considerably sick COVID-19 patients. This gives a trend of the expanse of the disease, ie if the cases are increasing or decreasing. If the number of tests is increased more, cases will be falsely positive if there are fewer actual cases among the tested and the test positivity will fall as a result, as this will fetch more of those who might be suffering from other diseases or are not infected. So it might not give a true estimate of the ground reality. False positivity, in fact, increases when an incidence or attack rate or a prevalence rate of a disease is less than 30 per cent in the population; on which right now, we have no information because of the apathy of those who are at the helm.

 

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).

Problems that lie in solution

An employee of Mugda Medical College Hospital sprays disinfectant after a lab technician collected a nasal swab sample from a 

   

 

 

An employee of Mugda Medical College Hospital sprays disinfectant after a lab technician collected a nasal swab sample from a resident to test for the COVID-19 coronavirus in Dhaka on June 17. — Agence France-Presse/Munir uz Zaman

IT TAKES 11 pieces of personal protection equipment to make a perfect full set which, however, may be too many and too much — two pairs of shoe covers, two pairs of hand gloves, one head cover, one full-length gown with a hood to cover the head, a pair of goggles, two masks and a face shield, all on top of a clinical dress. Most, however, think tnhat a pair of shoe cover, a gown with or without hood, a mask, a face shield and a pair of gloves should be enough. Whatever is the practice, in a hot and humid environment, these are too much to bear while giving medical care for long hours. We must realise that death of physicians, and also of law enforcers and journalists, caused by COVID-19 is the highest in Bangladesh of all such incidents worldwide. Can this be due to the poor quality of PPE components or not using them with enough caution and finesse?

Practice of wearing masks

WHAT percentage of people wear masks, what percentage of them wear quality masks, what percentage of them use good quality masks as long as necessary and what percentage of them use good quality masks properly? Nobody knows. It is not infrequent to see people loosening or removing it when talking, sipping tea outdoors or smoking, etc. We see people very often touching the middle of the mask every now and then to fix it and often the masks are worn loosely. Why do people behave this way with their masks? They may think either that masks are not that much necessary as advised or that that the way they use the masks are protective enough. Some complain of discomfort in using mask in hot and humid weather. The authority has not reached the people with a clear guidance yet in a serious and believable form.

Lay people are hardly aware that a mask should not be used for more than four to six hours and should immediately be changed if it gets wet during sneezing and coughing as in this situation, it cannot prevent SARS-CoV-2 from entering from the surrounding into a person’s nose or mouth. Masks, unless made of clothing, might not be used repeatedly as these cannot be washed for reuse. Some people keep it in open airy places at home or sun-dry them after a day’s use to reuse after a week — seven masks used on seven days and from the eighth day they start reusing the first one in a cycle, the efficacy of reused masks has not been studied though.

The other thing a few people know is that masks used by only an infected person is 50 per cent protective to a non-infected person. For an effective protection, the non-infected person also needs to wear a mask.

Distance between two, not living together

EVERYBODY out there is infected with SARS-CoV-2 — this is how one should think to be on the safe side. It is safe to maintain a distance of six feet and not three, as we do. Even when people would be advised to keep a distance of six feet, they will hardly abide by and by three feet, they would mean not even three feet and this is what we see. Why six feet? Because airborne aerosols from sneezing and coughing may move longer distance — up to 13 feet, as has been reported. Other measures which are hardly given importance too, which nevertheless are important, are not sitting face-to-face when talking at a meeting and not to be at a distance of six feet for long since the bolus/dose of virus is time-dependent. Every minute, 200 virus particles are exhaled by an infected while talking and 1,000 particles are enough to cause infection in a healthy person while one single sneezing or coughing is more than enough to cause infection.

Research opportunities not exploited

DOES the practice of hot gurgling, drinking hot water, tea and coffee, eating spices, eg cloves, ginger, turmeric, garlic, hot steam inhalation, etc prevent COVID-19? How much Vitamin C, zinc, Vitamin D and Vitamin K prevent the development of COVID-19? Can the practice of personal protection measures be better than enforcing lockdown? What percentage of people in the country has already been infected? What are the characteristics of the people who got infected and who died, eg age, sex, occupation, residential types and locations, literacy, socio-economic status? What are the type and strain of the virus that has affected the people of the country? Are the new strains more vicious or less harmful? These bits of information could be useful in controlling future incidence of the disease and its devastation. For example, if we could know for certain whether people who work in sunlight do not catch the virus and do not die or are less likely to die, we could inform the people of this fact and tell them what to do.

We have not conducted epidemiological studies such as basic reproduction numbers and not talked about the effective reproduction number. Instead, we believe in what scientists in other countries tell us. We have not studiud the pathogenesis, not conducted any diagnostic examination or biochemical estimation, and not followed the progress of clinical features or prognosis, clinical interventions and their outcomes. We have not explained why the red zone areas show an escalating estimation under lockdown and what has been the effect of lockdown in controlling the infection in non-lockdown areas. We have followed whatever the west has tried as copycats with astounding vigour and speed only to abandon soon enough, eg, hydroxychloroquine, remdisivir, flavipiravir and ivermectin. Hospitals infuse convalescent plasma from recovered patients to dying patients but without any matched controls to compare the outcome.

Believing the unbelievable

THE first information was that Bangladesh would experience 20 million death. Then, no mask is needed except for people taking care of infected people; and yet then, a distance of three feet only is enough. Then, symptomless infected people do not infect others. Yet then, infection does not impart immunity and then, hands should be washed every 30 minutes irrespective, of whether one has the probability of touching contaminated materials or not, etc. These bits of information were fed to us without considering if they are feasible or necessary at all in all weather conditions. Does Bangladesh have scarcity of good immunologists, virologists and epidemiologists from whom could seek opinions or advice on these controversial issues? Are we too gullible to question external expert opinions?

‘Back to the basics’, but where is it?

DOES anyone know what the incidence or attack rate of COVID-19 in Bangladesh is? Let us pick up another basic estimate. Do we know what the case fatality rate or the infection fatality rate from COVID-19 in Bangladesh is? The fundamental problem is that we do not have the denominator or, rather, a correct denominator for these estimates and not even the right kind of numerator for a true estimate in the past four months or so. The responsibility lies squarely on the people who call themselves public health experts and epidemiologists for not advising the government properly, the responsibility that they have been entrusted with. All what we know is the percentage of the people who tested positive and how many of the positive cases died. But we do not know the percentage of people, not tested, infected and dead. We do not know the percentage of people have developed antibodies, which could suggest what percentage of people might still be a potential threat of transmission of the virus. We do not know the effect of practising personal and family protective devices compared with lockdown.

Explanation of recent trend of test positivity

TESTS for COVID-19 have so far been carried out on people with overt clinical features and their contacts, way below the actual number, and also some amateurs, as the test was free. Two changes were brought in — test costs some money and cases only with clinical features are tested now. These strategies have shed off the amateurs with a larger prospect to be negative. This, therefore, exhibits a bigger rate of test positivity now. In all probability, a higher positivity rate may be apparent but not actual. For the same reason, the death rate among the tested is likely to be higher, which also may not be an actual accentuation of death. The other reason may be a lesser number of tests in areas suffering from flood, which, again, should not deter genuine cases from getting tested and being cared for in hospital. Climatic conditions might not hide the number of deaths.

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).

World Population Day 2020: Stalled progress, Covid-19 and the road to SDG

SOURCE: clicklancashire.com

Mushtaque Chowdhury

In 1989, the United Nations decided to observe July 11 as World Population Day every year in the wake of the world population reaching five billion. The purpose was to bring attention to the "health, development and environmental impacts of rapid population growth".  The world population has now risen to 7.8 billion, and in my own lifetime, it has more than trebled.

In the newly independent Bangladesh, "population explosion" was a huge worry. We have come a long way since then and it is no longer considered the nation's top problem. Thanks to the sustained attention and efforts of different stakeholders, Bangladesh is now a success story. In 1971, Bangladesh's total fertility rate (TFR), defined as the number of live births given by a woman at the end of her reproductive period, was over 6. It has now been reduced to 2.3, which is very close to what the demographers call the "replacement level". Similarly, in terms of other related parameters of population health, Bangladesh's progress over the past few decades has been exemplary. Maternal mortality ratio (MMR), defined as the number of women dying due to pregnancy and delivery-related complications per 100,000 live births, has been reduced from over 700 to less than 200 during the same period.

In 1975, I along with a group of fresh university graduates joined the Bangladesh Fertility Survey (BFS), one of the first population surveys done in the country. This took us to many nooks and corners of the country. BFS was a part of the worldwide fertility surveys carried out under the World Fertility Survey. When the results were published a year later, Bangladesh had one of the lowest rates of contraceptive prevalence (CPR)—only about eight percent of eligible couples were using some form of contraceptives. Family planning was a taboo and nobody wanted to talk about it openly. Our female colleagues in BFS had a really tough time to communicate this subject with village women.

Now, family planning is hardly a taboo—women freely talk about it even in front of menfolk. This is a revolution, particularly in the context of a conservative Muslim society. Soon after the BFS was over, I joined BRAC and was fortunate to spend extended periods of time in remote rural areas. It was pleasantly surprising to see how the organisation was promoting the concept of a small family being the norm. A study done in Sulla, a remote upazila of Sunamganj district, in collaboration with Cholera Research Laboratory (now Icddr,b) and Bangladesh Institute of Development Studies (BIDS), found the CPR to be 20 percent, the highest for that time in the country. The Bangladesh contraceptive revolution is owed to many—the government, NGOs, private sector, and development partners.

Unfortunately, the progress has now stalled. The TFR has remained the same for the past decade or more, and so has the CPR. The MMR and other health-related indicators have also stalled since 2010. This means we are perhaps not on track for the different targets of the Sustainable Development Goals (SDG).

Covid-19 threatens not only the continued progress but the sustenance of the gains we have made over the past several decades. Experts are concerned about the collateral effects of the pandemic on non-Covid health services. Vaccination coverage, maternity services including institutional delivery, contraceptive uptake and other services have marked a downward trend. This is because of both demand and supply factors. Potential users are apprehensive of contracting coronavirus when they visit a health centre. In the supply front, there is a drop in service provision due to diverted attention and resource flows to Covid-19 response and the presence of perennial governance issues including absenteeism. 

The theme for this year's World Population Day is "the sexual and reproductive health needs and vulnerabilities of women and girls during the pandemic". A recent UNFPA study estimates that if the lockdown continued for six months and there is major disruption to health services, both of which seem to be true in Bangladesh, then 47 million women in low and middle income countries (LMIC) would find it difficult to access modern contraceptives, leading to seven million unintended pregnancies. Apart from this, there would be a rise in gender-based violence, female genital mutilation and child marriages. Another study from the same agency predicted that a one-year average delay in implementing interventions to end child marriages could lead to 7.4 million new marriages taking place in the next decade. Pandemic-related economic downturn is estimated to result in an additional 5.6 million marriages over the same period—a total of 13 million child marriages during 2020-2030.

We in Bangladesh are already feeling this heat. In a webinar arranged by the Civil Society Platform for the SDGs a few days ago, NGO participants from different parts of the country raised their deep concern over rising child marriage in their localities. Helplessness of parents in the midst of the pandemic, social pressures, economic reasons and school closures are responsible for this sad state of affair.  

As a nation with so much of optimism and hope, we have to face these eventualities. Bangladesh is not unique in this situation. Such effects are being reported for many countries. In the United States, for example, a new "baby-boom" is being speculated by the end of 2020. To combat such a situation, agencies are initiating innovative solutions. PSI, an NGO, has initiated a new movement, "Flatten the boom", to inform potential boomers of the availability of alternative family planning services in their localities.

There are two immediate issues for us—containing Covid-19 and putting ourselves back on track for the SDGs.

The government has adopted several measures in combating the pandemic. There is evidence that it has achieved some early positive results. Containing it fully, however, will require more decisive measures. A lot on these latter measures has been discussed in the columns of this newspaper and other fora. What is most needed is a transparent, coordinated and science-based strategy that engages the whole of society and makes use of the assets we already have, such as community health workers. We need to go back to Bangabandhu's March 7 clarion call and empower and prepare every household for this protracted war.

It is clear that we are not on track to achieve the related targets of the Sustainable Development Goals. We have already faltered on the maternal mortality and fertility targets. The latest 2017 survey documented an MMR of 196 but, according to SDG targets, we are supposed to reach a ratio of 70 by 2030. Given the recent track record and the current Covid-19 onslaught, it is unlikely that we will achieve the SDG target unless some drastic and bold steps are taken. The progress we made until about 2010 was possible by making good use of some of the "low hanging fruits" such as easy availability of contraceptives, building new health centres, increasing vaccination coverage and acting on the social determinants of health including primary education, poverty alleviation, women's empowerment, and creating space for NGO and private sectors. Moving from here for a quantum leap forward will require utmost political commitment and imaginative solutions.

This will require greater focus on the "higher hanging fruits". It is imperative that the government move from a "business as usual" to a drastic reform of the health system that will involve but not be limited to setting up of a high-powered permanent national commission on health reforms; increasing investments for health; improving accountability, governance, transparency and management; streamlining data systems; strengthening primary health care; and engaging the whole of society. These, if done well, should lead to much-promised universal health coverage where every citizen will have access to quality healthcare without suffering financial hardships.

Covid-19 has shown how various countries have faced the crisis differently with varying results. One conclusion that has gone viral on social media is that the countries that have women at the helm have done exceedingly better than others. The countries in this list are Denmark, Finland, Germany, New Zealand, Iceland, Norway and Taiwan. We can definitely hope to be in this league! Can't we?

 Dr Mushtaque Chowdhury is the former Vice Chair of BRAC, Professor of Population & Family Health at Columbia University, and Convener of Bangladesh Health Watch.

COVID-19: points to ponder

Local ward council workers inform residents of Purba Rajabazar in Dhaka on PA system about dos and don’ts of the lockdown enforced in the area. — New Age/Sourav Lasker

THE Barisal division had 297 COVID-19 patients by the end of May; the number shot to 2,609 by June 28. This is 2.93 times higher every 14 days. In Bogura, the number of cases was 216 till May 31; this increased to 2,782 by June 29, indicating 3.6 times higher every two weeks. In Khulna, COVID-19 patients were only 76 on May 31. In a month, it increased to 1,551, or 4.5 times higher every two weeks. Barisal probably has the lowest immigration and emigration while Bogura is known to have experienced a high number of immigration compared with the districts in the Barishal or the Khulna division. These figures are too wide to say that they surrogate a basic reproduction number. It is an oversimplification and not an accurate process of estimating R0.

In the 12th week, May 24–30, since the first reported COVID-19 cases in Bangladesh, the daily number of cases had been 1,790. Two weeks later, in June 7–13,, it was 3,056 — about 1.7 times higher within a gap of one incubation period. In the 16th week, June 21–27, the number of cases was 3,600, which is 1.18 times higher than that of the 14th week. Are these correct reflections of R0? No, because cases were not decreasing and, rather, started increasing after the 12th week. If the R0 estimations at the district level seem unacceptable, why should R0, estimated in the same manner for the national level, be acceptable?

How to estimate R0

FOR R0 estimation, we need to identify index cases, in a defined static population in a defined geographical or administrative area to begin with, where people neither enter from outside nor leave it. The next step is to find out the people who came in contact with index cases and follow the contacts for about two weeks, the incubation period of COVID-19, assuming that everyone in the population is susceptible theoretically, to see if the contacts are infected — with or without any clinical features within 14 days. The no-in migration or no-out migration in the defined population and geographical or administrative area needs explanation. Emigration would reduce the number of people who either had a chance of developing the infection in the defined area or have already been infected but could not be measured for their infection status because of their emigration. While immigration would swell the number of infected people, who might have contacted it from the place where they moved in from, but without prior information on the status of infection and were not infected from index cases. A more practical proposition would be, however, to exclude those who moved in and show clinical features before 14 days and follow those up who moved out for 14 days.

The other reasons we cannot estimate R0 in Bangladesh is that the present figures available do not count all those who might have been infected actually, eg, infected without clinical features and infected with mild-to-moderate clinical features. Unless and until we know the full expanse of infection, how can we say how many people an index case transmitted the infection to within the incubation period of the disease?

Purba Razabazar lockdown

The 2011 census put the population of the neighbourhood in ward 40 u8nder the Tejgaon police jurisdiction area as 29,820. Based on the rate of increase of population in urban areas in Bangladesh, the projected population of Purba Razabazar is supposed to be 40,045 in 2020. This is about 20 per cent of the population of ward 40, ie only 0.22 per cent of the population of the Dhaka city.

It has been claimed that because of the lockdown, the number of cases fell at Purba Rajabazar. This begs a fundamental question: what is the aim of lockdown? The answer is to keep other people safe from the lockdown area. So, the effect should rather be measured in terms of how much the infection rate fell or did not increase among people outside Purba Rajabazar who were not in areas in lockdwon. This bit of information is not known to us. We do not know what the infection rate was at Purba Rajbazar to begin with. Infection among 60 per 100,000 people, applied to colour a location red, has been based on the infection among people with considerable clinical features of COVID-19 and their contacts which was, and still is, until the last bit of information that we have come across, only one per patient on an average which a figure hardly believable. One might argue that the way the infection is estimated now gives clue to the overall incidence. But we are not certain unless a population-based estimation is done on several locations at least once. One additional point in this regard is how locations with different administrative and population sizes may be compared with each other even if in terms of rates as the transmission potential should be different based on these differentials alone.

The fact that those who were without any overt features or who had mild symptoms do not appear in the estimation process proves that the estimation process does not give any incidence rate. Besides, were there not other areas where 99.88 per cent of the population of the city live which could also be coloured red at the same time? How can one expect that just by locking down only one of these areas will prevent the spread of the disease to other parts of the city?

Cases of COVID-19 fell at Purba Rajabazar; so was claimed. Nonetheless, it will be interesting to know if the fall was significant in statistical terms. We do not know. These questions and the issue of the actual incidence in the area will remain unanswered forever as the actual expanse or percentage of infection in the area was unknown ab initio. By the way, did the rate of COVID-19 infection not fall or at least not increase remarkably in other parts of the city? Was it due to the lockdown of a small 0.22 per cent of population of Dhaka city only?

When might a disease fall in a population?

HOW may the fall of a disease on a location be explained? The non-possibility of exposure of the people of a location, eg Purba Rajabazar, from extraneous sources, which, however, should be insignificant, as people from other areas of the city supposedly had a much lower infection rate with much lower possibility to transmit the virus to an area which supposedly had already a much higher rate. The other possibility is that everyone in the lockdown area became immune during the lockdown period, which, to be true, would mean that everyone was infected within the area due to interaction between them, chances are slim though. Yet another is that the virus died down within those who were infected and that it did not infect uninfected people in the area. This would be possible only if those who were ill from COVID-19 remained in isolation or the suspected ones kept them in quarantine and everyone else practised personal protective measures meticulously, which protected them from asymptomatic or mildly symptomatic carriers. Needless to say, this later measures could be equally effective if adopted in any other areas without lockdown. There may be yet another possibility that by the time the lockdown was applied, too many people were already infected and not many were left to be infected in the area, knowledge of which is, however, beyond our reach. A theory to be acceptable, namely, lockdown reduced the infection rate at Purba Rajabazar, a feasible explanation should be in order.

Fundamental effect of lockdown

ONE aim of lockdown is to keep the transmission of a disease under leash to buy time, which notwithstanding also reduces the number of infection, but does not bring it down to zero. The number starts climbing after a time to some extent, after the lifting of the lockdown. Could the pocket of new cases at Purba Rajabazar be a testimony to this fact, as is seen in many other countries?

 Fawning of reasoning

THE basic question at the end: how does putting a population of only 0.22 per cent in a city, with so much of population mobility, so many not bothering about personal protective measures and practices, can effect a fall in infection in other parts of the city? Are there not other sources and avenues of engendering infection? What will happen to the people of Purba Rajabazar who are free to mingle with other people now with a new found confidence that they are infallible? If all of them have really become immune already, there is no concern. But what if they are not? Who will ensure that those who were not infected at Purba Rajabazar already will neither get infected nor infect others in city areas which are not in lockdown. A two-way domino effect, in fact, is in the offing, now uninfected, residing in lockdown area, getting infected from non-lockdown areas after lifting the lockdown and vice versa.

Many states and countries needed re-imposition of lockdown. To be effective, lockdown has to be applied simultaneously to all applicable places based on an accurate rate and size of incidence.

The final question is whether we have compared the effect of lockdown with the adoption of strict personal practices and measures including quarantine and isolation?

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).

Covid-19: Community health workers as first line of defence

Until testing improves, CHWs’ reports on presumptive diagnosis of Covid-19 can help the government identify areas of risk and needs for lockdown or otherwise. This the final part of the two part series

Mushtaque Chowdhury (left) and Fawzia Rasheed (right).

The Covid-19 pandemic has spotlighted and added to the global crisis of the health workforce. Longstanding problems include shortages and a poor mix and distribution of workers in relation to public health needs, and providing equitable access.

Bangladesh, however, has assets that many countries do not: community health workers (CHW). The story behind these workers stems from the 1978 Alma Ata Conference on Primary Health Care which recommended CHWs as a way to promote health and prevent disease through working closely within communities. 

Who then are the CHWs? According to the World Health Organisation (WHO), "Community health workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organisation, and have shorter training than professional workers."

Over the last four decades, CHW programmes have been established across the world in high- and low-income countries. Based on the successes and value for money of community health workers, and in response to the Covid-19 crisis, the African Union, has just recommended recruitment of two million CHWs, in addition to a million that are already working in various African countries.

In a webinar arranged by AMREF, a regional NGO in East Africa, which we attended, the speakers narrated the successful use of CHWs in controlling Covid-19 in various African countries – not the least in behaviour change which is a vital part of the response.

Little known within Bangladesh is the fact that our CHW programmes are recognised worldwide. In a recent review of CHW programmes globally by Last Mile Health, a US-based think tank, Bangladesh was not only highlighted for its strengths in community health work, but was cited as an example of best practice.

If supported well, community health workers can certainly be effective frontline workers for Covid-19 control. PHOTO: SHEHZAD NOOORANI/BRAC

In this country, little is being said about CHWs in the discourse of and planning for Covid-19. Note that we have about 130,000 CHWs – 50,000 in the government, 50,000 in Brac and the rest in other NGOs. They are very significant assets.

In Brac, for example, CHWs include married women who are semi-literate, village-based, and are from relatively lower socio-economic segments of the society. They do not receive a salary but are provided with training as well as occasional incentives, including access to resources such as microfinance. Their work ranges from promoting healthy lifestyles, providing information on ways to prevent and treat common illnesses, and helping people detect and seek help for risks and early warning signals.

Relevant to Covid-19, their efforts with detecting and treating TB are heralded as a key reason for Bangladesh's ability to tackle TB. There is no doubt that much of Bangladesh's solid health gains of the last decades have rested upon the work of CHWs.

More recently, a selection of upgraded CHWs are being specially trained to identify and treat non-communicable diseases, such as diabetes and hypertension, and to recommend reading glasses to people with presbyopia. The successes have been such that the CHW model in Bangladesh has been exported to other countries, including Afghanistan, Liberia, South Sudan, and Uganda. A recent randomised control trial carried out by a Swedish university documented up to 26 percent reduction in childhood mortality in areas served by CHWs in Uganda.

If supported well, CHWs can certainly be effective frontline workers for Covid-19 control. As they do for other illnesses, CHWs can raise awareness of methods to prevent infection, and screen and provide basic care for the sick people within their own homes.

Again, similar to what CHWs do for other conditions, they can be easily trained to spot patients at risk, and refer those with the most complex of needs to hospitals. These are the principles of primary health care and we need this now more than ever. Our hospitals have limited support to offer and most of Covid-19-related illnesses can and should be dealt with at home.

Furthermore, if our hospitals are full, CHWs can coordinate with hospitals and alert the seriously sick as to when, if at all, they can be safely received and accommodated by hospitals. If there is no room, they can also be instrumental in providing care and medicines, as directed by doctors, and helping families make their sick members as comfortable as possible at home.

This approach is built on sound science and maximises the use of scarce resources. It also serves the interests of patients, their pockets and their time. It is also important to note that keeping patients away from health facilities helps reduce the spread of the virus among other sick people who are likely to suffer the worst, and among health workers who are already highly scarce and who we can ill afford to lose.

Furthermore, for each doctor, we now have hundreds of CHWs. Compared to doctors and nurses, CHWs cost less to train and pay, but also generally stay within their communities for years, if not for life.  As members of their communities, their voices are trusted, which is essential during epidemics, as they can not only help with guiding people on what to do but with dispelling myths and stigmas which are rampant.

Elsewhere in the world and, we are glad to see, in some parts of Bangladesh, CHWs have started to engage in Covid-19 response supported by governments and NGOs. CHWs use checklists of coronavirus symptoms to make a presumptive diagnosis. Until testing improves in Bangladesh, CHWs' reports on presumptive Covid-19 diagnosis can be instrumental in helping the government identify areas of risk and needs for lockdown or otherwise.

As trusted community members, CHWs are also experienced in supporting the coordination of non-health specific needs, including mental health, and have helped with emergency coordination many times in the past. We envisage them helping organise isolation spaces and support services for the vulnerable and sick; providing soap, disinfectants and food; and guiding safe burials of the dead.

But to work safely in this environment, CHWs have to be prioritised for supplying with the best of personal protective equipment. They should also be supported with testing and healthcare if they need it.

In the long-term interests of the health care sector of the country, we believe CHWs should be systematically trained and integrated within the health system. We would like to see that they are recognised at long last as valued health professionals, something they are, and are paid as such too. This, for Bangladesh, is well within the realms of what is possible.

Such choices should not be viewed as second-best solutions for the poor but the best bet for health, and for addressing this pandemic and others which are likely to come. We urge that we build on these tested local strengths as a priority rather than aiming to replicate high-cost medical interventions with limited, and in some instances, unproven, prospects of efficacy.

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Mushtaque Chowdhury is a professor of population and family health at Columbia University, and convener of Bangladesh Health Watch.

Fawzia Rasheed is a former senior policy adviser to the World Health Organisation

Covid-19 response: Inclusion as the first mantra

Community participation is even more pressing as the virus has already invaded most localities. This is the first of the two part series 

AInclusive and locally-led committees can help commandeer resources, influence behaviour change, and coordinate the needed initiatives within communities. Photo: Mumit Mdd caption

The people of Bangladesh are in the midst of one of the greatest challenges this country is likely to face in our lifetimes. The Covid-19 pandemic threatens lives and livelihoods at a time when Bangladesh was celebrating achievements in most socio-economic development sectors, many of which surpassed those of our economically powerful neighbours. 

Overcoming this colossal challenge requires education, participation and contribution of every citizen. We have seen how instructions on precautions have been and continue to be ignored. A recent large-scale survey, to be released soon by a private university, has documented the extent of current practices in different districts, which indicates an ominous picture. The widespread lack of the very minimum of steps to avoid an infection – even in so-called red zones – is dismaying. In the past, we as a nation faced and successfully overcame many disasters – floods, droughts, cyclones, wars and famine. A common success factor was the participation of citizens in the mitigation efforts. This was also true for how we successfully we tackled many serious public health problems which were holding the country back. 

From over six children per woman in the 1970s, the average fertility rate is just over two. Immunisation rates here are comparable to the wealthiest of countries.  Oral rehydration therapy was also developed and championed here. 

For these and many other health interventions, the government, sometimes in collaboration with non-governmental organisations, successfully mobilised the entire country, and was specifically inclusive of women, menfolk, local government, mosques, temples, schools, village practitioners and the medical community, as well as the civil society, NGOs, media, celebrities, students and teachers. In short, people from all walks of life were included, with a strong emphasis on rural communities. While these are all significant achievements, the interventions we need for Covid-19 are far more complex. 

Mushtaque Chowdhury

Unfortunately, we are missing an approach that makes us join hands in tackling the current crisis. We lack and sorely need a coordinated response at national and local levels. 

The government's National Preparedness Response Plan for Covid-19 (dated March 2020) indicates the formation of different national- and local-level committees, which is good news. However, these committees, while not the only means for coordination, seem to have missed the critical element of including people from the many sectors essential to the response – including, for instance, the non-governmental organisations and the private sector. 

Economists and social scientists are also missing from the technical committee – their expertise is surely vital. The current thinking seems to view Covid-19 as a medical problem. Certainly, two of the most important national committees (National Coordination Committee and National Technical Committee) are both headed by the Directorate General of Health Services. Unfortunately, the challenges we face go well beyond health. 

Just a cursory look at what others are doing shows the importance of not only bringing in a wide array of skills, but also ensuring guidance that is fact-based and transparent. Rwanda, which has mounted an exemplary response, immediately constituted a national steering and technical committee made up of all government agencies, as well as the private sector representatives from all sectors. Their rationale stemmed from acknowledging the need for diversity to provide insights into the affected sectors and to improve the relevance of interventions. 

Many countries have taken a similar whole-of-government approach and widened the network beyond traditional advisers. Interestingly, the UK's Scientific Advisory Group for Emergencies (SAGE) started with membership from a broad array of experts representing almost all conceivable interest groups, headed by the country's Chief Scientific Adviser. And yet, with time, an additional independent SAGE was formed with people exclusively from outside the government. 

In other words, while careful attention to relevant insights and stakeholder involvement is needed, it is not enough. Independence is also emerging as a vital component of leadership in these times. As with other countries, we will learn as this complex crisis develops. We should, however, not lose time to position ourselves to do the best we can do. We can and will, we hope, do and think better. 

Despite the current difficulties, people from different sectors and walks of life are not sitting idle. We are aware of several initiatives started by people taking charge of the situation themselves and as best they can – occasionally with the government, too. A Corona Resilient Village Programme, spearheaded by the Hunger Project, is making people aware of the disease and the need to religiously follow the health etiquettes, in 1,500 villages.

Brac, through its extensive network and in collaboration with the health ministry and others, is organising community support teams in different villages to raise awareness and identify suspected cases for referrals and support. A further example with signs of progress is a partnership forged between the civil surgeons and other administrative wings of the government, local members of the civil society, and non-resident Bangladeshis. 

Pulled together by the Sylhet-based Kidney Foundation, two large isolation centres are being set up amid a surge of Covid-19 and Covid-19-like infections which have already overwhelmed the existing local capacities. The government lent its two new yet-to-be commissioned upazila health complex buildings in Khadimpara and South Surma, and local volunteers along with non-resident Sylhet residents provided most of the financing and human resource support. 

Community participation is even more pressing as the virus has already invaded most localities. We have a long way to go and urgently need to establish community-based responses in terms of prevention, case detection/contact tracing, and provisions for home-based care and isolating cases. From whatever evidence we have seen, people are ready to take on the challenge to defeat the virus, but they need to be rallied and supported as it happened in 1971.

Fawzia Rasheed

This far, Vietnam remains a success story in the fight against Covid-19, with no reported deaths. There, the government ensured that the public was on board for their sweeping and aggressive strategy to work. According to a senior official, "We have to mobilise all of society to the best of our capability to fight the outbreak together". 

Active participation of community is also said to be a major factor in containing the disease in India's Kerala state.  Kerala, like Bangladesh, had a significant number of non-resident Keralites who returned home after the crisis began. They were allocated specific care centres to wait out a period of quarantine. Supervised by the village panchayat, community health workers provided awareness, identified symptomatic cases and strictly enforced the initial lockdown. 

We have much to learn from the Kerala example. In Bangladesh, overseen by the union parishads and implemented by NGOs, broad-based village-level Covid-19 prevention committees can take the lead in prevention and initial management of suspected cases. Such committees can also be entrusted with the task of distributing food to vulnerable families. The Corona Resilient Village programme, as mentioned above, has already shown that these types of measures are entirely possible and feasible.  

With the government's backing, inclusive and locally-led committees can help commandeer resources, influence behaviour change, and coordinate the needed initiatives within communities. If provided with information, small financing, and planning support, such committees can achieve a great deal – more than what is possible through externally imposed or piece-meal partnerships. 

While mistakes will surely be made as this crisis unfolds, the chances of better outcomes and accepting the consequences of actions will surely increase if decision-making is locally-led and engagement is inclusive.  

Mushtaque Chowdhury is a professor of population and family health at Columbia University, and convener of Bangladesh Health Watch. Fawzia Rasheed is a former senior policy adviser to the World Health Organisation

জিতে যাব আমরা ২

”জিতে যাব আমরা” করোনা মোকাবলোয় বাংলাদেশ হেলথ ওয়াচ এর আরেকটি সচেতনতামূলক প্রচারণা...

“জিতে যাব আমরা” করোনা মহামারির ভয় ও স্টিগমা নিয়ে গবেষণার ফলাফলের ভিত্তিতে বাংলাদেশ হেলথ ওয়াচের একটি প্রচারণামূলক উদ্যোগ। গবেষণাটি থেকে আমরা জেনেছি কিভাবে এই ভয় ও স্টিগমা কোভিড-আক্রান্ত রোগী এবং তাদের পরিবার, স্বাস্থ্যসেবা প্রদানকারী ও অন্যান্যদের জীবনকে দূর্বিষহ করে তুলেছে।
আমরা দৃঢ় প্রত্যয়ী - এই প্রচারণার মাধ্যমে আমরা আরো সচেতন হবো, আরো সতর্ক হবো এবং এভাবে শীগগিরই এই মহামারি মোকাবেলায় জয়ী হব।

https://www.youtube.com/watch?v=kuGWEH9Ia3g