‘We started to fight the greatest pandemic of our time with limited resources’

Dr. Arif Mahmud has been actively involved in Covid-19 management from the onset of this pandemic. He attends media and social activities to create awareness among the general people on current public health issues. 

In a recent conversation with The Business Standard, he spoke about the healthcare management system of Bangladesh and addressed issues pertaining to healthcare during the Covid-19 era. 

TBS: The statistics suggest that around 1.6 crore  people have been fully vaccinated in Bangladesh. How do you assess this progress of vaccination?

Dr. Arif Mahmud: See, the current vaccination statistics cover around 9 to 10 percent of our population. We must acquire herd immunity and ensure vaccination of 85 percent of people to overcome Covid-19. It is a huge task because it requires the vaccination of approximately 14 crore people. 

Our honourable Prime Minister Sheikh Hasina has declared that 85 percent of our population will come under vaccination coverage by next year. To that end, recently, a memorandum of understanding (MoU) was signed between our government, China's Sinopharm and Bangladesh's Incepta Pharmaceuticals Ltd for the co-production of Covid-19 vaccine. According to our prime minister's direction, Bangladesh will produce 10 million doses a month in the next two months. This procedure will surely propel us to our ultimate goal of herd immunity. 

TBS: How has our healthcare industry changed or modified to mitigate the Covid-19 cases? 

Mahmud: Well, we must follow some steps to prevent a health-related disaster. We cannot think of fighting Covid-19 without a proper epidemic plan that includes proper prevention, mitigation, preparedness responses and recovery process. We know the first Covid-19 case was found on 8 March last year in Bangladesh. By that time, we had only nearly months to prepare ourselves (since Covid-19 was confirmed in Wuhan in December 2019). That was not enough for us, albeit it was the most challenging phase for us.  

We still lack resources. We started with limited resources to fight the greatest pandemic of the time. But I must say that things have changed over time. Bangladesh health sector tackled the Covid-19 situation effectively with collaboration and partnership with different stakeholders. 

Let me give a few examples. You see, at first, IEDCR was the only authority to run tests. Now we have 810 licensed authorities running tests across the countries. We didn't have enough High Flow Nasal cannula, ICU beds, and isolation facilities. But gradually our government has increased those facilities and, in effect, our capabilities to fight this pandemic. 

Our death rate is 1.7% which is much better than the western world. We have established a central oxygen system, portable oxygen, proper isolation beds and field hospitals in different parts of our country. 

TBS : How do you prepare a hospital to fight against an epidemic?

Mahmud: Hospitals play a critical role in providing essential medical care to the community during crises such as an epidemic or a pandemic. To enhance the readiness to cope with the challenges, hospital managers need to ensure the initiation of relevant priority action. 

A standard checklist is very helpful in this context. Following principal should be incorporated in each facilities: 1) Establishment of Incident Command System and Leadership Commitment, 2) Risk Communication and Coordination with different stakeholders, 3) Safety and security of staff and patients, 4) Establishment of proper triaging in Emergency Room and entry point of Out-Patient Department, 5) Infection control and prevention policies and practices, 6) Surge and Resurge Capacity, 7) Continuity of essential medical services by creating appropriate zones, h) Planning and utilisation of human resources; and i) Logistics and Supply chain management.

TBS: What is the main problem in our fight against Covid-19 pandemic?

Mahmud: We don't follow the health safety rules properly. However, new cases have lessened in the last few days. And the infectivity rate lies below 6 percent now. 

Our main shortcoming is that we have not been able to engage mass people in this battle. People were reluctant to wear masks. In public health, community engagement and risk communication are two vital components.

Although the government has built Covid-19 Prevention Committees in every union and village, we are yet to establish engagement with mass people properly. Usually, Covid-19 cases and infection rate (along with casualties) ascend to the peak and then drop down. It remains stable for one to two months and then another wave starts. The cases must drop below 5 percent for a minimum of two weeks in a locality. Then we can call it under control.  

TBS: How much has our hospital management improved during this pandemic?

Mahmud: Well, we must operate an epidemic drill every year to prevent infectious diseases and prepare our healthcare facilities to face health crises in a better and stronger way. Healthcare authorities should draw an epidemic/disaster plan, then brainstorm, prepare action cards for each member and run mock drills to ensure that epidemic plan works properly before another epidemic or disaster hits.  

Developing an Incident Command/management system is our top most priority. As you know, initially we struggled to fight. However, the Health Ministry is now leading the Covid-19 situation from the front. 

But we lack components like community engagement and skilled human resources. We have a scarcity of doctors and nurses in our country. Our numbers are much lower than the benchmark set by WHO. 

The healthcare staff initially suffered a lot due to lack of  proper Infection and Prevention Control (IPC) practices. There was no committee or team to ensure proper guidelines and policies. We hardly knew the rules of donning and doffing of PPE. As a result, 183 doctors died of Covid-19. 

Around 3,118 doctors and 2,281 nurses have been infected with Covid-19 so far. These events initiated a negative impact on the healthcare system. 

But we have gotten over the primary trauma. The overall healthcare system has had rapid development in accordance with the necessary needs. We developed a triage system in every hospital. It helps to segregate normal patients from those with Covid-19 symptoms. We also adopted a zoning system that is colour-coded red (for confirmed Covid-19 patients), grey (for suspected of Covid-19 patients) and green (non-Covid patients). 

As a result, death rates and positivity rates have lessened down. Hospitals are safer now. 

TBS: How is the state of affairs in the public health sector outside the capital city, along with the infrastructure and facilities? 

Mahmud: During the first waves, our health care system was mostly Dhaka-based. But the delta variant entered Bangladesh through the borders, and changed that. During that time, Covid-19 healthcare management was expanded all over the country. 

We have primary health care, Upazila health complex, district-level hospital and divisional level hospitals. We also have community clinics across the country. Unfortunately, we have a limited number of specialised hospitals. And most of them are located in divisional headquarters. 

If we want to design our future plan based on the experiences gathered from the Covid-19 era, we must decentralise our healthcare system and ensure the digitisation of the industry. IT-based healthcare is undoubtedly a requirement in the modern world. 

TBS: What difference is an IT-based system likely to make and what facilities will it provide? 

Mahmud: We can develop apps and digitalisation for various medical facilities. Those apps can be used to detect infectious areas and set a proper management map. Unfortunately, we have a scarcity of ICU beds. But if we initiate the e-ICU project, a consultant from Dhaka will monitor four to five hospitals from the centre. 

This way, local correspondents can upload a patient's data on a central interface and specialised doctors will be able to diagnose from a distant hospital. In a Covid-19 free world, we should develop a 'unique number' for medical reports. No doubt, it is a real hassle for patients to carry big medical files to their doctor. This unique number will help physicians find all the medical records by just clicking on a digital file.

TBS: How responsive the government and other organisations have been towards marginal groups and underprivileged people? 

Mahmud: No doubt, we have to ensure more facilities for the underprivileged and marginal communities. According to government plans, there should be no differences among communities in terms of access to healthcare services. Marginal communities must be enlisted into the NID database. 

Most importantly, we have to change our outlooks and behaviour towards them. We are entitled to follow SDG goals. Goal 3 aspires to ensure health and well-being for all and it aims to achieve Universal Health coverage health by 2030. I hope it will help us provide healthcare services to people of every socio-cultural background. 

TBS: When shall we possibly be ready to return to normal life? 

Mahmud: It's difficult to predict. Without proper research, we can't reach any conclusion. Right now, our target is to gain herd immunity. We want to bring 80-85 percent of our population under the vaccination programme by next year. 

We need to continue wearing masks, practicing washing hands and have to maintain social or physical distance at the same time. It seems Covid-19 will not leave us soon, rather we have to live with it for a long time.