No alternative to a long-term plan
The tragic scale of this year's dengue outbreak is a cumulative result of global atrocities against climate; our national failure in healthcare, city, and social behaviour management and policy structures; and the overall abysmal response to the situation. A multitude of studies predicts that dengue, the fastest-spreading tropical disease according to WHO, and other arboviral diseases will increase multifold in the near future. And so, we need to systematically restructure our society and institutions as soon as possible if we want to tackle these growing public health threats.
Dengue is emerging as a greater global threat than ever before, with a more than eightfold increase in yearly reported cases worldwide since 2000. Asia and South America are both experiencing one of the worst instances of dengue outbreaks on record, and Bangladesh is witnessing its worst numbers this year – with 466 lives lost and 97,860 reported cases as of August 19. Our healthcare system is already overwhelmed, and if the trend continues, it may crumble in the coming months.
Our authorities cannot evade responsibility for these dreadful figures. Despite repeated warnings, unnerving predictions, and pleas for measures to mitigate the threat, from both local and global experts and organisations, our healthcare and disease-prevention efforts failed to show sincerity and effectiveness. In West Bengal, which shares many of our geological and sociological factors, authorities have been quite successful in controlling the Aedes mosquito population by implementing a year-long vector surveillance strategy, WHO guidelines, and a sustained implementation structure.
Twenty-three years have passed since Bangladesh's first dengue cases, and we are yet to form a national vector-control policy, an integrated vector and virus surveillance system, or any coordinated dengue outbreak mitigation guidelines. The vector-control strategy here still resorts mostly to fogging, which is proven to be practically ineffective in the long term, according to multiple studies. Even then, we are failing miserably as reports show that many of the personnel assigned lack knowledge of the effective dosage or procedure of fogging, let alone WHO guidelines.
We must consider dengue prevention and overall public health as an essential investment priority, not just a reactive expense.
In 2018, the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) found that mosquitoes here have developed strong resistance to traditional insecticides. But Transparency International Bangladesh (TIB) says that at least one major government official ordered for the findings to not be published to the media because it was during an election year. Plus, many other officials labelled the scale of dengue threat that year as gujob (hearsay or rumours). The following year, Bangladesh faced its worst dengue outbreak up until that time. Experts now warn that this misuse of fogging is creating a shift in vector characteristics, and mosquitoes are adapting to breed in not just clear water in small containers, but also in water canals, lakes, floodwater, etc.
Over the years, Dhaka has become a perfect breeding ground for mosquitoes, with plenty of unregulated high-rises, government-owned backyards, construction sites, discarded tires, drums, and plastic waste just lying around, and clusters of people living in damp, concrete messes which sunlight can barely touch. The capital's two city corporations barely pose a threat to these tiny insects. They don't monitor or properly implement their own or global guidelines and aren't proactive in using newer vector-control tools. Three years have passed since the city corporations were authorised to reclaim and maintain the canals. Yet, in most places, the canals remain as garbage-filled swamps.
A study published in the International Journal of Environmental Research and Public Health finds a correlation between Dhaka's increasing temperature and growing numbers of Aedes mosquitoes, which is, in turn, the result of receding water bodies and increasing unplanned urbanisation. The result: over half the reported dengue cases and deaths are recorded in Dhaka. In July, when fatalities were breaking all previous records, the DNCC mayor went on a 17-day overseas tour, without leaving any promising guidelines to curb the situation.
It's true that dengue is a global problem, with WHO warning it to be a "pandemic threat" back in January this year and pointing towards climate change as one of the leading factors for the worsening situation. But we can't just wait for a global response for an effective mitigation solution. We have to realise that we are one of the frontier countries fighting this global threat, along with other climate change-related phenomena. We cannot afford to consider it as just another monsoon incident and wait for the situation to get worse every year before beginning to actually take worthwhile actions.
First and foremost, we need a comprehensive, long-term policy for addressing dengue and other weather-based diseases. We need a strategy for how to prevent outbreaks and a clear guideline on how to mitigate severity if major outbreaks do occur. We need coordinated efforts from city corporations, the medical and pharmaceutical sectors, tech industries, relevant ministries, law enforcement, urban planners, research institutions, engineers, academia, and all other stakeholders concerned.
We must consider dengue prevention and overall public health as an essential investment priority, not just a reactive expense. A 2021 study found that the aggregate total economic expenditure of patients (including treatment costs and productivity losses) only in Dhaka city that year was more than Tk 130 crore. In addition, every dengue outbreak forces the government to incur mammoth expenses and relocate supplies for mitigation efforts. A well-maintained environment and a soundly structured healthcare system are necessities for tackling dengue outbreaks. We should allocate a larger share of the national budget to public health (which was surprisingly reduced this year) and ensure proper implementation. Bangladesh has to emerge as a frontline dengue-prevention strategist, regional and global collaboration advocate, and a voice for including tropical diseases as an element for climate-change compensation from the "developed" world.
We need to implement new-age tools, both to operate a thorough, widespread, and continuous surveillance system and also for vector control. Our cities need to be rigorously fixed and aligned to minimise vector habitation. We must also develop an urban design guideline incorporating dengue and other arboviral disease-controlling pointers, and be strict in implementation.
It's time we broaden our focus beyond the big cities and to the vast rural and hill regions. The condition of social awareness, medical support, testing facilities, surveillance operations, and overall investment outside the cities is still grossly inadequate. This forces patients from all over the country to flock towards big cities, which overwhelms the hospitals there and increases the possibility of a wider spread of infection. Currently, the Institute of Epidemiology, Disease Control and Research is operating from just one office in Dhaka. We need its operation to be more robust and cover the entire country.
As a society, we have to accept that the changing weather patterns and that the increased risk of tropical diseases is our new reality. We need to make a habit of not disposing of garbage all over the streets, between buildings, in the water bodies. Eradicating vector habitations, as a practice, has to be embedded in our culture. And the authorities have to provide proper support, with comprehensive waste management systems and city maintenance guidelines. Community-based awareness and clean-up groups can be formed to encourage more social engagement.
There's no case of sustained dengue eradication in the world yet. Dengue has only been successfully prevented through vector control in just three instances over history by Pan American Sanitary Board, Cuba, and Singapore from mid- to late-20th century. But all these successful cases were a result of extensive national-level coordinated efforts by the respective governments. Our government must therefore act with absolute urgency, sincerity, and transparency – or else the blight of dengue will not spare us anytime soon.
Naimul Alam Alvi is a member of the editorial team at The Daily Star.