Bewildered? Me Too!

When things that apparently do not make sense happen, they present a potential learning opportunity. All of us have a mental model of what we expect the world to be. We feel dissonant and lost when our model of the world and reality do not match.

Consider the following that have recently preoccupied most of our thoughts.

Off again, on again lockdowns

The nationwide "lockdown" was lifted ahead of the Eid al-Adha festival even as new infections persist at record levels. Millions of people are heading back to their villages to mark Eid al-Adha with their families. Except the public health community, there appeared to be little collective will against the reopening, despite the numbers, and the increased transmissibility of the Delta variant, which now reportedly accounts for 80% of infections.

The health committee that advises the government on how to manage the pandemic opposed the easing of the "strict lockdown", notwithstanding its palpable lack of enforcement. The public health specialists continue to expect stricter enforcement of lockdown despite overwhelming evidence to the contrary. The health of millions of people is at risk since herd immunity has not been reached and a vast majority of people extremely vulnerable to Covid-19 are unvaccinated. They fear that crowding at markets to buy cattle and big gatherings during the festival could become super-spreader events. Their fears are not unfounded as evident from the post Eid-ul-Fitr community transmission trends.

The government will impose a "complete lockdown" for two weeks from 23 July. In theory, all government, semi-government, autonomous and private offices, factories, shops, markets, tourist centres, resorts, community and recreation centres will remain closed. Operation of public road, rail, water and air transport and all types of motorised vehicles will be suspended except for movement of goods. All public gatherings such as wedding ceremonies, birthdays, picnics, parties, political and religious ceremonies will be suspended.

From a public health standpoint, when the positivity rate is persistent at high levels and the health system is struggling to cope, the time for a high intensity lockdown is immediate for two to three weeks.

An anathema to the business community

Factory owners describe the decision to close factories as suicidal. Any pause in production will put the exporters in deep trouble. The order will shift to other countries. No competing countries such as China, Vietnam and Cambodia are in lockdown now. If they were, the argument then will be that orders diverted from them will not come to Bangladesh. Thus, no matter what, the local suppliers will be distressed. Domestic market-based industries fear damage to inventories, cashflow crisis, working capital deficit, employment losses and you name it.

What about the infection risk? Industry owners claim factories are safer than where the workers live. Owners have adopted the necessary safety measures prescribed under the government's guidelines. Shop owners say ditto. The safety measures are enough to protect the workers from Covid-19, their leaders assure. Last year they feared allowing workers to return to their village homes will spread the virus from urban hotspots to rural areas. This year they are worried workers may carry the virus from rural to urban areas when they return after the Eid holidays and subsequent lockdown.

From a business standpoint, the right time for a high intensity lockdown of the kind planned from 23 July is almost never and the duration nearly zero.

Bewildering experience

Successful pandemic response strategy requires following the basics of infectious disease epidemiology, infection prevention and control. The connecting links in the chain of infection must be broken to effectively slow and eliminate transmission. Non-pharmaceutical interventions have been key to breaking the links.

A strict lockdown strategy is generally deployed as a first-line, time-bound pandemic response to buy time to scale up response capabilities. Failing to do that, the overall rationale for its use loses power especially in terms of the balance of the burdens over the benefits. Lockdown does not work as a continuous containment policy when the pandemic is protracted as is the case now in Bangladesh.

Compliance with mobility restrictions is hard to sustain economically and socially for long periods of time. The public fails to comply with mobility restrictions out of necessity, curiosity, and bewilderment about the point of a lockdown that is not manifest in public interactions. People do not comply because they think enforcement is weak and enforcement is weak because of non-compliance – a breeding ground for self-fulfilling prophecies on the futility of lockdowns.

It is hard for people to give up social interactions and personal economic opportunities when everyone else is doing it. It feels futile. And yet if you have not acted on a personal level, the dominant narrative makes you feel guilty, making it hard to hold politicians and businesses accountable. At the same time, it is quite easy to put the onus on personal responsibility and blame the population.

Lockdown, as implemented, seemed to have made little difference to the infection rate and the pressure on the health system. The positivity rate has hovered around 30% throughout the lockdown period, compared to 10% or so a month ago. The official death count is approaching 18,000. Hospitalisation rates have remained high. The virus is breaking through vaccination and youth.

What is really gained from the adoption of highly diluted forms of lockdowns that pay little attention to disease epidemiology is not clear. A fully enforced high intensity lockdown for a limited period flattens the curve, but lockdowns with lacklustre enforcement gets what?

Will the next one be any different no matter how we label it?

Stumbles in the vaccination campaign

We are likely to face successive waves of infections in the foreseeable future. Restrictions with intensity high enough to break the connecting links have eluded us. The growing lockdown fatigue is not making it any easier. Virologists and scientists believe that the key to beating the virus under such circumstances is to vaccinate the vulnerable. Vaccine rollout can break the link between infections and severe illness.

We have faced considerable delays in scaling up vaccination. So far, 4.2 million people have been fully vaccinated. Another 1.6 million have received one shot. Availability, not purchasing power, appeared as the most binding constraint early on.

Vaccines have begun to arrive. Including AstraZeneca, 16 million doses have so far arrived and another 21 million or so are visible in the pipeline. To vaccinate 80% of the population, Bangladesh needs 270 million doses in quick time. You would think our vaccine stock is not even remotely close to enough, including the ones in the pipeline.

But no! The official view is that the issues surrounding the vaccine stock in the country have now been "resolved". At the same time, they urge those who "have no urgency" to get jabbed to wait with patience after registration. Who does not have vaccination urgency other than those who are vaccinated? Even the infected people are eager to be vaccinated.

Vaccination took a while to restart. The Pfizer doses were given a dry run for 7 to 10 days before giving approval. "We need to wait to see any side-effects of the vaccine," said senior public health officials of the DGHS. This notwithstanding data on hundreds and millions who received these jabs all over the world since January this year with an efficacy rate of over 94% in trials. Not surprisingly, no issues were reported in administering the Pfizer vaccine.

It took time to prepare a priority list for vaccination. Since the arrival of the Pfizer vaccine, people have been lobbying the health officials to get their shots. Sorting out who not to include and who to give which vaccine was time consuming. Bangladeshi migrants have long been demanding vaccination acceptable to their host governments. The authorities finally moved at end-June to vaccinate the migrant workers.

The full readiness to vaccinate is still missing. Both the Pfizer and Moderna vaccines must be stored and shipped at ultra-cool temperatures. With limited cold chain facilities, Bangladesh is administering the Pfizer vaccine at a few centres in Dhaka. Another 6 million Pfizer and Moderna vaccines are set to arrive by the end of this month. Due to a lack of capacity for maintaining a proper storage temperature, the government has requested staggering the shipment.

The slow pace of the vaccination drive, coupled with nonadherence to the non-pharmaceutical basics, leave room for more lethal, infectious, and transmissible variants to develop and spread. High levels of vaccine coverage are central to keep the economy going. But the authorities have made clear it will take at least a year to reach the coverage needed for herd immunity, notwithstanding the claim that the vaccine problem is "solved". Until then both containment and mitigation measures will be needed.

Will the disconnects connect?

Being aware of things that do not make sense provokes efforts to find the missing link, the x-factor that you may have ignored. That x-factor is not so obvious when everything around you, everything you are thinking and feeling and what you are currently experiencing personally appear to not fit the dominant narratives. You feel like a detached observer, watching from a disconnected vantage point with no possible way to reconnect yourself to reality.

You are not alone. How can there be such an incredible disconnect? How do we remain focused on systemic, scalable, and workable solutions to the crisis? At some point, the disconnects will end, probably brutally in ways impossible to foretell.

Much has been made of the need to balance public health measures and the economy. Our recent experience shows that locking down the economy did not contain the disease's spread and keeping it open barely nursed recovery without unleashing an economic boom. Some argue restrictions did not go far enough. Others maintain the attempted cures have been worse than the disease.

One reason for these conflicting views is that the answer depends on both facts and values. We say policy decisions ought to be based on science and evidence. The problem is which science and data matter to some people is different from the science and data that matter to others.

This is the new age of bewilderment with alternative everything – science, facts and values!