Prof. Muzaherul Huq, former adviser, South-East Asia region, World Health Organization (WHO), and founder, Public Health Foundation of Bangladesh, talks to Naznin Tithi of The Daily Star about the way forward in our fight to contain the spread of Covid-19.
How would you evaluate the Covid-19 situation in Bangladesh? What's your take on the zoning system proposed by the government which is already being enforced in some areas on a trial basis to contain the spread of the virus?
There are ways to ease lockdown in a scientific way and the WHO has some specific suggestions on how and when to do it. The number one suggestion given by the WHO is that a country must control the transmission before easing the lockdown, which, unfortunately, has not been the case in Bangladesh. Also, the principles of enforcing a lockdown had not been properly followed here. As a result, the transmission has spread further and the number of deaths has also increased.
About the zoning system, I congratulate the government for taking this decision but I have some reservations about it too. My suggestion was to implement a district-wise zoning system. If we could divide the 64 districts into red, yellow and green zones, and completely enforce lockdown in the red zones, we would get the expected result.
There was a time when only a number of people were infected with Covid-19 in a few districts. But instead of shutting down those districts, the government enforced a lockdown in the whole country, which was a wrong decision at that time.
Let me give you an example of how the zoning system should work. My home district Munshiganj has about 600 Covid-19 patients now. Five to six lakh people live in each of the six upazilas of the district. In Srinagar upazila, the number of infected people is around 60. If 60 people out of 6 lakh are infected, it should not be very difficult to control the spread in the upazila. We can easily limit the transmission by isolating these 60 people in the upazila health complex or in a hospital or their homes, and quarantine the 300 people who came in contact with them (assuming that each infected person could spread the virus to at least five persons) in a school. Also, Dhaka being a Covid-19 hotspot, no one from Dhaka should be allowed to enter Srinagar during the lockdown period. However, all the economic activities of the upazila can continue.
Locking down a particular area might bring some good results in that area if all the principles of a lockdown are properly followed. However, it will not improve the overall situation of Dhaka. Also, lockdown should be enforced in the red zones for at least three weeks—a 15-day lockdown will not have much of an impact. During this lockdown, our aim should be to detect every Covid-19 patient, do proper contract tracing, and quarantine the infected and those who came in contact with them.
What should be our containment plan for Dhaka given its high population density?
The transmission in New York City could be contained through taking only three measures: imposing lockdown, conducting contract tracing and carrying out as many tests as possible. We also need to strictly enforce these measures to contain the transmission in Dhaka. I once suggested that makeshift quarantine facilities be built on the Ijtema ground or in Kurmitola stadium with proper toilet facilities. While the infected people should be isolated in hospitals, those who have come in contact with them should be kept in the quarantine facilities.
Based on the official numbers of confirmed cases and deaths, is it possible to guess when we might be reaching the peak of the curve?
Firstly, the number of positive cases that we have now is not the real number of people infected in the country. It is the number of people infected among the number of people tested. With increased tests, the number will also increase. So, we cannot predict the real number of infections until we make tests widely available and easily affordable to all.
If we only consider the available information to understand the disease curve (since we do not know the real number of infections), we still see that it is steadily climbing. But as we have been conducting tests on a limited scale, nobody can scientifically predict when we will be reaching the peak.
Now, the basic principle to contain the transmission should be that not a single person can be left undetected. One undetected person will spread the virus to three to five persons, and those five persons each will spread it to another five persons. So, we need to bring the whole country under the purview of tests and ensure proper contract tracing.
What are your thoughts on herd immunity?
Bangladesh cannot afford to achieve herd immunity because of its population density and its unprepared healthcare system. The only countries that had tried to go for herd immunity were the UK and Sweden. England later abandoned the idea and went for a lockdown while Sweden has never imposed a lockdown. However, Sweden has been enforcing strict measures such as social distancing and health hygiene protocols as well as implementing some laws to control the transmission. The country also has specific directives on reopening the shops, restaurants and factories. This is by far the only country in the world that did not go for lockdown and is still thinking about herd immunity.
But for Bangladesh, such a decision will only end in a disaster. If we have to achieve herd immunity, 80 percent of our population—13.5 to 14 crore of our 17 crore people—will have to be infected. Since 15 percent of the infected people need to go into isolation in hospitals on an average, more than two crore of our population will have to go into isolation. Among these two crore people, five percent will need ICU facilities. In a normal situation, 2/3 ICU beds are needed for every lakh of people. While we need to have 5,500 ICU beds in our hospitals in a normal situation, our public and private hospitals combined have only 1,200 ICU beds now. Thus, if we go for herd immunity and five percent of our two crore people need ICU facilities, we will need some 10 lakh ICU beds which our health system will never be able to afford. Therefore, we have to contain the spread of the virus at all costs, which is the only available option for us.
What can Bangladesh learn from other countries' experiences?
While there are countries that are conducting more than one lakh tests every day, our number of tests is limited between 10,000 and 15,000 per day. All the SAARC countries except Afghanistan are conducting more tests than Bangladesh. The sooner we will increase the number of tests, the better result we will get.
In Kathmandu, Nepal, the lockdown has not been eased yet. People are staying at home while only police and the military are on the streets. Only one person from each family is allowed to go out to buy the groceries and other daily necessities within a fixed time. In Colombo, Sri Lanka, the government announced a curfew to contain the spread of the virus. Although Sri Lanka is now easing the lockdown, they are doing so following the WHO guidelines. These are some examples that Bangladesh can learn from.
How can we prepare our healthcare system for the coming days?
In order to provide treatment to the growing number of Covid-19 patients, we need to completely overhaul our healthcare system. First, we need to bring all the public and private hospitals—both at the national level as well as at the district and upazila (sub-district) level—under a common management system through public-private partnerships. Without a well-coordinated response, this grave health crisis cannot be handled. Let me mention some steps that should be taken immediately.
Let's start from the upazila level. Isolation facilities must be ensured at the upazila level hospitals which should also have the necessary equipment such as oxygen masks, nasal cannula, oximeters and an oxygen supply system in cylinders, to provide treatment to the Covid-19 patients. As skilled manpower will be needed to operate the equipment, the healthcare workers across the country should be provided with necessary training immediately. If we can treat Covid-19 patients at the upazila level hospitals, the national level hospitals will not be overburdened with patients.
In the district level hospitals, there should be ICU beds, ventilators and oxygen storage facilities. I particularly thank our prime minister for directing all district level hospitals to arrange for ICU beds. I think a deadline should also be set by the government in this regard.
And since all the national level hospitals are overburdened with patients, ICU facilities at these hospitals should be increased in proportion to the number of people in the divisional cities. I propose that there should be 300 ICU beds in Chattogram while in Dhaka the number should be increased to 2,000 immediately. I would also suggest that the government should give the responsibility of containing the transmission in each district to the civil surgeons of the district.
If we can take these decisions on a priority basis, we may expect to see a change in the Covid-19 situation in the country. So let's take the right decisions now and implement those decisions with sincerity.