Wobbling as the going gets tough | The Daily Star
12:00 AM, April 26, 2020 / LAST MODIFIED: 01:59 AM, April 26, 2020

Wobbling as the going gets tough

Critically under-resourced public health system failing to rise to the outbreak challenge

On April 14, a doctor at the surgery department of Sir Salimullah Medical College Hospital sent The Daily Star a list of protective gear they were supplied that day.

Quoting the relevant entry, signed by the department's assistant registrar, the doctor said there were eight caps, 28 pieces of gloves, 10 masks and a half bottle of Hexisol in total.

"This is the supply for a 30-hour shift. The department has 7-12 doctors and interns. We will be seeing 200-250 patients," the physician said that day, adding, "The masks were not standard N95 ones either."

Two days later, five doctors, four nurses and three ward helpers of that very department were found to be Covid-19 positive. Two more tested positive the next day.

The doctors suspect they contracted the virus from one patient from Gazipur, who went to the department with volvulus (twisted bowels) on April 11. The woman needed an emergency surgery and the doctors dutifully performed it. Later, it was found she had been carrying the coronavirus.

That one patient was all it took to infect so many health professionals, because they did not have proper protection.

The doctors are now fundraising to buy their own protective equipment, unwilling to take any more risks.

As the news spread among the community, other physicians started taking to social media with photos of their own flimsy protection gear. Aminul Mamun, an anesthesiologist at Dhaka Medical College Hospital (DMCH) recently posted to Mohanagar General Hospital to treat coronavirus patients, sent photos of his "gloves".

For a 12-hour shift, Aminul was given one set of flimsy disposable polythene gloves instead of nitrile or latex gloves. These polythene gloves are the types used by baristas in coffee shops.

His PPE too was of the thin material that disposable medical aprons are made of. In case a coronavirus patient sneezes or accidentally spits, the PPE might absorb it, exposing the skin to the deadly virus.

This is one of the 12,52,233 PPE units distributed by the government to doctors and other health workers, according to data disseminated by the Directorate General of Health Services (DGHS).

This correspondent then asked the doctor whether there could be cross-contamination from one patient to another with only one pair of disposable gloves. "There is a hundred percent chance of that," he said with finality.

A quick survey was done by Brac University's James P Grant School of Public Health, on the perceptions of frontline workers regarding the crisis.

They had talked to a total of 60 respondents from 14 districts and 43 health facilities (including those which are dedicated coronavirus hospitals) and found that respondents said the PPE they received was inadequate to protect them. In addition, of the total workforce, 75 percent of the doctors and nurses received PPE. For the support staff, it is 40 percent.

More than a month into the crisis, how is it that the hospitals are still not adequately provided with tools essential to battle the pandemic?

The answer lies in the very dilapidated nature of the country's health sector itself.

"One virus has completely broken down our health system. This is a wakeup call. How do we restructure our health system to respond?" asked Dr Mushtaque Chowdhury, vice chairperson of Brac.

DGHS's own "National Preparedness and Response Plan for Covid-19" created earlier last month put it bluntly.

"About 3 percent of Bangladesh's GDP is spent on health; out of which the government contribution is about 1.1 percent. In term(s) of dollar(s), the total health expenditure in the country is about $12 per capita per annum, of which the public health expenditure is around $4," states the document.

Four dollars, or Tk 344 approximately, less than the price of a restaurant meal, is what the government spends yearly on the health of each person in the country.

As a result, when reporters of this newspaper, including this correspondent, visited seven public hospitals last month during the second week of the pandemic in Bangladesh, they found nurses carrying their own soaps in the pockets of their lab coats, and doctors buying their own disposable masks. Gloves, PPE and N95 masks were nowhere in sight.

According to the Bangladesh Health Facility Survey 2017, this was the kind of healthcare system the pandemic has attacked: 47 percent of district and upazila facilities, and 85 percent of union-level facilities did not have alcohol-based disinfectants; 43 percent of district and upazila facilities and 72 percent of union level facilities did not have masks; 52 percent of district and upazila facilities and 77 percent of union-level facilities did not have gowns.

A quarter of district facilities and a third of union facilities did not even have soap. Only 12.5 percent of district and 4.8 percent of union facilities had eye protection.

It was only on March 19 this year, which is at the end of the second week of the coronavirus crisis in the country, that the DGHS announced through a press statement that it has distributed 6,940 units of PPE.

It has been more than a month since then and healthcare workers allege they are still not getting adequate PPE.

On the other hand, on March 26, the government went right ahead and instructed doctors and nurses to at least give primary healthcare to patients with Covid-19-like symptoms, even if they do not have protection. The order, however, was withdrawn almost immediately in face of criticism.

In fact, this delay was codified into the national Covid-19 response plan itself. The plan categorises the pandemic into four stages -- stages 1 and 2 are preparedness, stage 3 is containment, and stage 4 is mitigation.

In the "preparedness" phase, supplying hospitals with protection was not a part of the government's own plan. This step was to be taken afterwards, during the "containment" phase, when the virus had already spread through.

"Our preparedness happened later. It took us a while to react. Up until mid-March, we were all in a denial state saying that we have nothing to fear about. From the government, there was a minimum effort. In February, there were no measures. It was only in March, that we saw some measures," said Dr Fahmida Khatun, executive director of Centre for Policy Dialogue (CPD).

This level of underpreparedness is also reflected in the provision of health-care to patients.

For the longest time, the healthcare system has functioned out of the pockets of the general public, stated experts.

"In the last several years, the budgetary allocation for health has not gone above 1 percent. The finance ministry allocated Tk 250 crore to tackle the crisis, but it is still not enough," said Dr Khatun.

On April 17, Health Minister Zahid Maleque addressed the public and listed a number of new hospitals to provide healthcare to coronavirus patients, in addition to Kuwait Maitree, Kurmitola General Hospital and Mugda Medical. These hospitals include Lal Kuthi Hospital, Mohanagar General Hospital, Railway General Hospital and the DMCH's Burn and Plastic Surgery Unit.

Unfortunately, at least three of them do not have any ventilators yet.

"I am supposed to build a 5-bed ICU with 5 ventilators, but it has not been built yet. I do not know when it will be built. I have 18 coronavirus patients in my hospital and if they need ICU facilities, I will have to look for empty beds in Kurmitola hospital, or any of the others," said Dr Shamsul Karim, director of Lal Kuthi Hospital.

The director of Railway General Hospital, Dr Firoz Alamgir, had a similar story to tell. "This was never an inpatient facility to begin with. We had to start from scratch to build a 100-bed hospital. Right now, there are no intensive care facilities, or ventilators. We can only take care of patients who do not need critical care."

Doctors from Mohanagar General Hospital also stated that they have no ventilators.

Ventilators pump oxygen into the lungs of patients suffering from severe pulmonary stress or patients unable to breathe on their own anymore. For patients with the worst effects of the coronavirus infection, a ventilator offers the best chance of survival.

But maybe ventilators are a far cry, when a majority of the public facilities were not adequately prepared to even provide support for acute respiratory symptoms, when coronavirus outbreak began.

According to the National Health Facility Survey 2017, 30 percent of district and upazila facilities had no access to oxygen, and that number was 93 percent for union level facilities.

Almost none of the facilities had life-saving medication for patients with breathing difficulties like epinephrine or prednisolone. Less than half of districts, and none of the union-level facilities had hydrocortisone injections.

These always had to be bought and managed by patients privately. Now the healthcare system is suddenly trying to provide these services since the pandemic struck.

"We have been talking about universal health coverage but have not done much about it," said Dr Mushtaque Chowdhury.

"Our focus had been on public health, rather than facilities. As of yet we are not being able to feel the main pressure. When the number of cases is on the rise, then will be the actual trial. How much we can perform, can truly be seen then," he said.

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