The University of Cambridge epidemiologist speaks about the low prevalence of infections in South Asia and the possible pitfalls of easing lockdown without safeguards
Bangladesh reported its first three cases of coronavirus infection on March 8, and the first death ten days later. The virus has infected 8,238 persons and claimed the lives of 170 others in the country until May 1.
The Business Standard recently reached out to Dr Rajiv Chowdhury, senior epidemiologist and associate professor of Global Health at the University of Cambridge to discuss the Covid-19 situation in Bangladesh.
In the conversation Dr Chowdhury spoke about the spike in cases, impact of opening garments factories, weak enforcement of social distancing and the response of the healthcare system to the pandemic.
The Business Standard (TBS): Europe recorded a very high death toll despite having very strong healthcare facilities. However, the Indian subcontinent with poor healthcare facilities has a low death rate. Why is that so?
Dr Rajiv Chowdhury (RC): There could be several possible reasons for this discrepancy.
First, the age distribution in European countries is very different, where you have a more elderly (and hence at risk) population compared to our South Asian countries. For example, in Europe, 20-30 percent of the population could be over 65 years of age, whereas this would be around 5 percent in Bangladesh.
Second, there are key health system-related differences between South Asia and Europe. For example, in most European countries there is a nationwide death registration system, which is able to capture and document all deaths by cause. This is not the case in South Asia, so we are not able to document all deaths, especially those occurring at the community-level.
Third, the lack of testing. Compared to the European countries, we have done far less number of Covid-19 diagnostic tests. For example, in the UK around 10,000 tests have been done for every 10 lakh people. In Italy, this statistic is around 30,000 per 10 lakh people.
By contrast, this test statistic is only around 700 in Pakistan, 800 in Sri Lanka, 500 in India and 350 in Bangladesh.
So, when people die in South Asia, without a confirmatory Covid-19 test, it is impossible to say if that person died due to heart failure, or stroke, or asthma – or if it was, in fact, Covid-19 infection, which led to those complications in that person to cause her/his death.
Finally, in theory, one can also argue that in South Asia, we may be protected from Covid- 19 related adverse outcomes by some not-yet-characterised population-specific features, such as our lifelong exposure to many widely prevalent infections since our childhood – providing us some immune advantage to fight off Covid-19. However, there is no evidence currently to support such a hypothesis.
Therefore, I would say that the lower number of deaths we see in South Asia is an artefact, rather than a reality, which is driven by mainly under-ascertainment or misclassification of deaths, and the population differences.
TBS: A huge number of RMG workers have returned to work as many factories resumed operations on April 27. What impact will it have on the current status of Covid-19 infections in Bangladesh?
RC: In developing country settings, we now face a strategic dilemma about how to balance between saving lives from Covid-19 and ensuring that people are still able to put food on their table. Since most people in Bangladesh work in informal sectors, and live from day-to-day, prolonged lockdowns mean inevitable hardship and hunger for many people in this country (who have no social safety-net).
So, I think we need to consider a way to find a sweet spot between health protection and preventing economic collapse. Many developing nations, including Bangladesh, are already considering relaxing the lockdown, so that the economies can "breathe".
But this relaxation needs to be based on some sensible criteria (e.g. if we see that the disease incidence has come down, the number of deaths have reduced). This also requires a well thought out "exit plan" that provides a standard guideline to the businesses or institutions about individual safety, physical distancing and basic prevention strategies that must be maintained.
Opening up the businesses without such measures may mean rapid resurgence of the epidemic. Therefore, if we must lift the lockdown, we should do so based on a carefully-devised strategy and not haste (opening up without a clear guideline could be catastrophic with a far more deadlier second wave).
TBS: Bangladesh reported its first three cases on March 8. In the last 50 days, the number jumped to 5,913 (April 27). Do you think the government failed in preventing more infections?
RC: To be fair, Covid-19 has been challenging for all governments worldwide. You cannot prepare enough for a problem of this scale and speed.
The very nature of this virus is that it can spread rapidly, in a so-called "exponential" manner, making this extremely difficult to contain, even in industrialised settings.
So, I do not think that we have reached a point yet, where we can judge whether a government has failed or succeeded. We are still very much at war with this virus and this battle is always going to be a tough one if you are running a country with high population-density, high population-mobility, but with poor health systems resilience and poor awareness.
Therefore, I believe that it's not what the government could (or could not) do at the beginning that we should discuss now (even influential global health institutions like the World Health Organisation made early strategic errors), what strategy and collaborations we do, from this point forward, should be the main focus.
As an example, as soon as the UK government realised that their initial approach of "herd immunity" was flawed, their response was a rapid U-turn from that strategy. Therefore, going forward, it is really such informed, flexible leadership that we should show to help tackle this situation.
TBS: In an over-populated country like Bangladesh, what are the immediate steps that the government should take to flatten the curve?
RC: Several steps can be done to achieve this.
First, by shielding our elderly and people with co-morbid conditions (e.g. people living with lung, heart disease or diabetes) until we have a vaccine.
Second, by strengthening our test-trace-isolate approach. We can achieve this by adapting a scalable diagnostic plan (e.g. a cheap but reasonably sensitive point-of-care test), and by mobilising available health workforce in both public and private sectors (e.g. community health workers who can use help in the contact-tracing process).
Third, by extending focus on hospital care for "less complicated" cases. These are cases that do not need ICU care but require basic hospital support (e.g. managing oxygenation and fluid status for symptomatic relief). Strengthening the basic care facilities for this group of people (around 20%-30% of all cases need hospitalisation) at primary care level can help minimise their potential progression to ICU, and serve as an effective referral system and impact case-fatality rates.
Fourth, by considering "zonal lockdowns", when needed, to minimise sudden suspected outbreaks in a "hotspot".
Fifth, by ensuring physical distancing and hygiene measures in place for the workers, if the lockdown is lifted (e.g. wearing nasal masks, hand washing facilities, physical distancing in work environment, general awareness training).
Sixth, by continuing to restrict large gatherings (e.g. less than 50 people) which serve as effective vehicles for a rapid community spread.
Seventh, by ensuring basic protection equipment for people. This considers: a) making it compulsory to wear nasal masks by everyone whenever they leave home, and b) increasing the availability of WHO-grade PPEs for frontline health workers (e.g. by mobilising the local garments sector).
TBS: Can "social distancing" work in Bangladesh, given that a huge population of the country live in the cities and commute in public transports?
RC: Strict nationwide social distancing (like lockdowns) in a resource-poor country like Bangladesh can only work for some time. If these socially disruptive measures are imposed or enforced for too long, there will be knock-on effects on people's livelihood, and therefore, people will fail to comply.
But if the measures are relaxed, we have to focus on simple, feasible, locally-appropriate preventive measures (e.g. wearing masks and gloves) and "physical" distancing as much as possible.
With respect to public transportation, it is tough. But we can think of out-of-box measures, for example by leaving seats half-empty on the buses or trains, restricting passenger numbers in "tempos", "CNGs" and "rickshaws" etc. This is not easy, but desperate times call for desperate measures, and allowing a "business-as-usual" approach would be a mistake.
TBS: Are we doing enough tests? In case of lifting the lockdown, how should the government respond in testing, isolating, distancing and quarantine?
RC: As mentioned earlier, we are behind the test-per-population statistic compared to many regional and Western countries. We will have to try to catch up.
But the measures need to be resource-appropriate, and that's why I am in support of a sensitive, cheap, point-of-care test (Senegal is an excellent example in this regard where rolling out a cheap testing measure helped the disease containment efforts and reduced death significantly).
TBS: A group of Bangladeshi scientists says it has developed a rapid coronavirus testing kit that can detect Covid-19 in less than 15 minutes. It is also very affordable. How reliable is it?
RC: I have not seen any validation data (with respect to sensitivity or specificity) of this new testing kit – so, it is difficult to comment. But in principle, a cheap rapid test sounds attractive, and surely deserves a chance to be validated using Bangladeshi samples.
We should consider fast-tracking the admin processes needed to start this study, given time-sensitivity of the matter and potential high implications of this test in transforming our national testing capacity.
TBS: Survivors of Covid-19 have narrated stories of negligence and poor medical attention. How should the doctors act in handling coronavirus patients?
RC: The problem of negligence and stigmatisation in Bangladesh can be major social drivers of poor outcomes in Covid-19. These attitudes typically originate from fear and misinformation about the disease.
So we must ensure that we spread the right information about the disease to reduce undue fear: that is, anyone can have this infection, that it is crucial not to hide the symptoms, and that given the right treatment, most people can survive the disease.
As for medical doctors, they are our best hope in tackling this pandemic. In Bangladesh, all our health workforce are doing their best, given the pre-existing limitations that we have as a poor health system. What we should, however, focus on is the support that they need (e.g. our compassion to them, due protection from financial hardship, access to PPEs, and training- where needed about this new disease).
TBS: We are quite far from finding a possible vaccine. Right now, what measures should people take to keep themselves safe from the virus, in case the lockdown is lifted?
RC: In case the lockdown is lifted in near future, I will advise the following simple measures:
First, wear nasal masks, whenever you are going outside. Especially, when you are in so-called "high viral-load" environments, such as in a public transport, a super shop/ bazaar, a hospital/clinic, or a crowded office environment like a bank, post office etc. Also, wear a nasal mask at home if anyone in your house has Covid-19 like symptoms or have tested positive.
Second, avoid going to large gatherings, only leave home if you must have to. Work from home, if you are able to do that.
Third, maintain all the basic hygiene (e.g. hand washing) and physical distancing (e.g. staying at least 6 feet apart from another person, not shaking hands), in case you are going out.
Fourth, try to learn about the symptoms of the disease from reliable sources (e.g. health care workers or government leaflets/websites).
Fifth, maintain your general health (and immune function). This can help to prepare your body to successfully fight off the infection. Follow simple steps, such as avoidance of smoking, taking your hypertension and diabetes medications regularly, doing some physical exercise/work every day, eating healthily (e.g. with a diet high in vegetables and fruits, and low in salt and sugar), sleeping well and not distressing about Covid-19 (e.g. by spending times with family, meditation or prayers at home).
Finally, if you develop symptoms, please do not hide them from a doctor or your family members. Wear a mask at all times and seek medical help, as advised by the local health authorities, to save yourself and the others around you.