Planning for the worst

Bangladesh government’s “National Preparedness and Response Plan for Covid-19” obtained by Netra News — is the government following its own plan?

Planning for the worst

Bangladesh is on split screen. On one side there are the official figures showing that, as of April 2nd, only 56 people — including deaths — have been infected with the Covid-19 virus. On the other side are the various worst case scenario projections about the effect of the virus. One projection by a group of Bangladeshi and US-based public health researchers suggest that without government interventions there could be over 500,000 Covid-19 deaths by the end of May. Another estimate in an interagency United Nations planning memo, suggests that the number of deaths in Bangladesh can be as high as two million in a “no intervention” scenario. The difference between the official figures and these projections could not be starker.

In Bangladesh, most of the people only know about the official figures. The government is doing everything it can do to hide reports about these projections from its citizens, including blocking the mirror website of Netra News, which first published details of the paper by the researchers and the UN memo. Yet, information has seeped through social media and without any guidance from the government, many are wondering what to believe.

With such a low number of Covid-19 cases and just a few deaths, it is quite easy for people to imagine that Bangladesh has “jumped the shark” and unlike many other countries will not suffer the massive number of cases, contrary to the projections. Some even talk about the possibility — still unverified — that the country’s hot and humid weather will reduce the virulence of the virus.

However, there are reasons against optimism.

First, there is the issue of testing. Bangladesh has conducted a very low number of tests — a total of 1,643 samples in a total population of over 161 million. As reported by the Dhaka Tribune earlier this week, this test rate of 10 per million people is the “lowest in the world.” Since Tuesday (April 1st), only 141 people were tested. When Bangladesh increases its testing, in all likelihood, it will detect many more cases.

Secondly, while six Covid-19 deaths in Bangladesh may appear a small number, experience with this virus in other parts of the world shows that this number can reach hundreds and then even thousands in a matter of days. In the United Kingdom, for example, the first Covid-19 death was on March 1st. Then on March 10th, there were just six deaths (like Bangladesh now). And, just 20 days later, on April 2nd, there were 2961 deaths. Government health officials in the UK are now saying that the country will have “done well” if they could keep the total Covid-19 death toll under 20,000. In the United States, there were only 7 Covid-19 deaths on March 13th, and just over two weeks later, on April 2nd, there were 4513 deaths. President Trump is now saying that “keeping the US Covid-19 deaths [under] 100,000 would be a very good job.”

Time will tell if Bangladesh defies the predictions, but the government should show no signs of complacency and prepare for the worst. And, as it happens, the government indeed has a plan. The plan, titled “National Preparedness and Response Plan for Covid-19, Bangladesh”, was prepared by the Ministry of Health and Family Welfare.

As the planning document notes at the outset, “The Covid-19 epidemic is an emergency situation and the impact in terms of morbidity and mortality, social and economic consequences might be huge.”

The national plan divides the country response into four levels: Level 1 is when “no cases is detected in the country”; Level 2 is when “imported cases and limited human-human transmission” has occurred; Level 3 is when there is a “cluster of cases” and the government should initiate actions aimed at “containment” of the virus; and, Level 4 — the highest level — is when “community transmission” has started and the government should be involved in “mitigation”.

According to the plan, at Levels 1 and 2, there are a total of 64 “preparatory” actions that should be undertaken. These include preparing “isolation wards in all governmental hospitals” and “establish[ing] intensive care capacity at the divisional and district levels”. These are, as the plan says, a matter of priority.

As of April 1st, according to the Health Emergency Operation Centre and Control Room data, the Bangladesh government has identified a total of about 6065 isolation beds: 1050 are in the capital city of Dhaka; 4515 are in district hospitals and the medical college hospitals within the districts; and, another 500 are at smaller hospitals at the sub-district level. The piece of land in Tongi, that is used for the Ijtema, is also being turned into a makeshift hospital by the army, but it is not clear how many beds are being prepared.

4515 isolation beds in district hospitals outside the Dhaka city.

According to the “no intervention” scenario projection by the Bangladeshi and US-based public health researchers, by around April 16th, all of these beds will be filled up with patients. There are about 5000 private hospitals in Bangladesh, but these are not included in the government’s preparations.

When it comes to intensive care capacity for dealing with Covid-19, there are currently only 45 intensive care beds available in Bangladesh, and all of them are in Dhaka — 16 other ICU beds are being set up in different parts of the country. According to the projections by the researchers, by April 6th, there will be around 43 Covid-19 patients in need of “critical care”, presumably in intensive care beds. The remaining 16 beds, assuming they are operational by then, will be required two days later.

1045 isolation beds and 45 ICU beds in Dhaka city.

This lack of sufficient medical facilities cannot be laid squarely at the government’s doors. Though Bangladesh is moving towards middle income status, the country remains relatively poor and cannot be expected to have health facilities that match richer countries. However, the government’s budgetary allocation for healthcare in 2019/20 is only 1.02% of the country’s GDP. In 2018, its healthcare spending was the lowest percentage among the Saarc countries. In 2016, Bangladesh was ranked fifth from the bottom out of 182 countries, in percentage of GDP spent on healthcare.

According to the national Covid-19 plan, in the preparatory stages, the government was also supposed to have developed “national guidelines and SOP [standard operating procedure] for managing patients with Covid-19 symptoms at healthcare facilities”, and established “infection source controls, administrative controls and engineering controls” at all designated healthcare facilities. It is not clear if these steps were completed.

At Level 3, which has a total of 66 actions, the plan foresees “strict infection prevention control” at all the hospitals and preparation for “community quarantine”. At this point, the government is supposed to “enhance suspected case detention […] in healthcare facilities and in the communities” and “expand […] laboratory network and testing capacity.” The plan also requires the government to “set up and train multiple contact teams, comprised of thoroughly trained […] healthcare workers” and “ensure availability of proper transportation for the transfer of contacts who developed symptoms compatible with Covid-19 to designated isolation facility for further medical assessment and investigation”.

At Level 4, which Bangladesh has most likely reached already, there are a total of 55 actions. At this stage, the government is supposed to “prepare and build capacity for overwhelming patient load at primary, secondary and tertiary care levels” and “ensure a widespread comprehensive medical, psycho social and other auxiliary care for Covid-19 patients.”

It is difficult to know whether the government has completed the activities set out in its own plan, as it has made so little information public. Based on the “National Preparedness and Response Plan for Covid-19, Bangladesh”, journalists in Bangladesh should now be able to question the government more directly about the extent of the plan’s implementation.

Bangladesh may avoid the quagmire by planning for the worst.●

David Bergman (@TheDavidBergman) — a journalist based in Britain — is Editor, English of Netra News.

🔗 United Nations interagency Covid-19 memo: Without interventions, “upto 2 million” people may die in Bangladesh

🔗 Covid-19: Without government action, over 500,000 may die in Bangladesh

🔗 Health spending as percent of GDP — country rankings