While the virus does not discriminate, health systems do

March 27, 2020

Growing up in a house composed of doctors and public health professionals, I am no stranger to dinner conversations quickly turning to blood, mucus and infectious diseases. In high population countries like Bangladesh, health systems are constantly overwhelmed; WHO estimates the doctor-patient ratio to be 3.05 physicians for every 10,000 people. Of the country's 165 million people, 24 percent still live in poverty and don't always have access to health services. 

"We are constantly finding hacks so we can subsidise care for those who cannot afford it," my father tells us over dinner. "We don't want to turn anyone away." On average, between my parents, brother and cousins, my family treats 500 patients a day. They are not easily alarmed.

Since coronavirus broke out, we have been unnervingly quiet during meals. On most evenings, my brother or cousins don't even make it to dinner.

At the time of writing this piece, Bangladesh has reported 39 confirmed Covid-19 cases. This is a small number relative to nearly half million confirmed cases worldwide. However, global development practitioners like me are deeply skeptical of the numbers. According to UN Habitat, Dhaka is the world's most densely populated city with 44,500 people per square kilometre. In other words, it is a hotbed for a highly contagious virus to incubate and spread rapidly — and the city is likely to become the next deadly frontier of the pandemic.

Depending on the survey, some 2.5 to 4 million people live in the city's 5000 slums. Their income largely come from informal occupations — rickshaw van pullers, cleaners, vegetable sellers and house help. They have no savings against economic shocks and negligible access to primary healthcare, sanitation or government services. Data from UNICEF show 75 percent of slum households live in one room, which makes it impossible for them to self-quarantine or socially distance themselves. Twenty-four percent of residents report they suffer from chronic illnesses. Heightened exposure to crowds, poor living and health conditions, and necessity to commute daily to earn (less than) minimum wages make them more likely than others to be infected by coronavirus. They are also least likely to be prioritised for testing. 

The World Health Organization (WHO) has called upon countries to "test, test, test"; however the reality is that there just isn't enough testing kits available. The government in Bangladesh has allowed only one public institution in the country to test for Covid-19, although recently announced capacity of other laboratories around the country can be leveraged to increase the number of tests per day. With no centralised, systemic guideline and handful of trained staff, most people who are calling the government's coronavirus hotline cannot go through. Scare resources and indecisiveness further plunged the country's testing capacity. Between January and March this year, the country opened borders to over 650,000 travelers, including sizeable numbers of Bangladeshi migrant workers from WHO Level 2 and 3 countries. Inability to adequately quarantine confirmed cases and track contact with suspected cases allowed most returnees to travel domestically, risking unmonitored community transmission among rural and suburban populations where even fewer facilities and testing options are available.

Further, the country does not have sufficient number or design of quarantine facilities and does not have enough ICUs or ventilators to support infected cases. Yesterday, the government announced six hospitals have been fully prepared and specialised to treat Covid-19 patients, 14,565 isolations beds are now available and 290 institutions can provide quarantine facilities. Studies have shown at least 5 percent asthma prevalence rate in urban and 3 percent in rural areas. The numbers are woefully low for a population headed towards a likely outbreak. The scarcity will disproportionately affect the poor, who are typically at the lower end of the totem pole when it comes to receiving basic services, including emergency healthcare and income.

The country's economic policy has historically been anchored on rural development. In the past four decades, Bangladesh has experienced rapid, unplanned urbanisation. In Dhaka alone, the annual growth rate is 3.5 percent, largely because of rural-urban migration and climate shocks. The migrants constantly move between slums and informal jobs, making it challenging and expensive to build robust, accurate databases around them. As a result, urban poor in slums remain a blind spot in Bangladesh's social protection programming. Injecting emergency income therefore comes with the added challenge of targeting, given the country's existing governance challenges. With the government's decision to shut down non-essential services, most low-income urban settlers on a daily pay cycle and no permanent housing have been forced to travel back in masses to villages, likely further spreading the pathogen. An outbreak that may lead to the government place the country under temporary lock down will inevitably and rapidly push the poor and informal labour force into extreme poverty. Despite stimulus packages such as $590m announced by government last night to cover wages of nearly 4.1 million workers in the readymade garments industry, there still remains gaps in timely disbursement of the package and effective and direct transfer to their accounts. On the longer term, the pandemic has resulted the industry—that employs predominantly women—to lose $1.5 billion in orders from global brands and risks lop siding their ability to come back to work. If Covid-19 does not kill, poverty will.

Since the outbreak, my brother and cousins are on 40-60-hour shifts because of increased caseload in the emergency room. Public hospitals suspect there are far more cases than being reported or positively tested. Doctors are reporting on dire shortage of protective gear, sanitizers and ventilators. "Many doctors that are working with cases are reporting of symptoms or afraid to come to work," my cousin, who is a general practitioner at Dhaka Medical College and Hospital, tells me. "We don't even have basic surgical masks. If we continue being dangerously exposed, there will be no trained doctors left when we reach a peak. We needed strong awareness among the public yesterday. We needed the government to procure supplies yesterday."

The government and local NGOs have initiated awareness campaigns, but messages are not reaching people. Multiple sources and reports confirm terms like "isolation", "quarantine" or "social distancing" have no resonance among the residents. Most publicly available communication and social media posts are copied from Western outlets, meaning they are not translated and lack cultural context. Even if information were made widely available, urban poor, in particular, do not have financial resilience that provides them with the option to stay at home and flatten the curve.

"There is no credible economic or epidemiological modeling that is telling us what to anticipate and what we need to prepare for," my father muttered in a dry voice during dinner earlier this week. "If we are struggling now at the hospitals, we will completely collapse when the outbreak happens. We are not far from becoming another Italy, but I suspect it will be far more catastrophic for us."

Sabhanaz Rashid Diya is a computational social scientist working in global development.

Originally published in The Daily Star on March 27, 2020.