Farida Akhter || Wednesday 01 April 2020
In a country where health care facilities are already inadequate, how can the government and private hospitals are shutting down their medical services? A largely unnoticed, undeclared and sinister shut down of outdoor, indoor and emergency services raises serious questions about the right to health, more so during the time of COVID 19 pandemic. This is a picture of healthcare situation after the novel corona virus (COVID 19) outbreak in the country since 8th March, 2020 depicting serious violation of human of human rights. What should we contemplate to do immediately?
Systematic Denial of Health Service
Novel Corona virus (COVID 19) outbreak around the globe, in Bangladesh, so far only 54 detected and 6 death cases were found (1 April, 2020). On the other hand, more people are dying of simple cold-fever-flu because of non-availability of treatment. These patients were not tested, but were suspected of Corona virus by the local level doctors and therefore refused treatment. To maintain the celebratory national mood for a grand national occasion, the imminent danger of COVID 19 was underplayed, often the existence of virus-affected people and deaths has been denied and a strategy of refusing test except returnees from COVID 19 affected countries, led to a total mess. It also created a stigma against the returnees, the remittance earners of the country, and were blamed for bringing the ‘misfortune’ to the country. There was delay in the preparedness of the government to tackle such a virulent virus epidemic. Government undertook no plan to protect healthcare professionals, doctors, nurses, ward boys and others support staffs. Unavailability of Personal Protection Equipment (PPE) became the major arena of contestation and concern that inhibited health professionals to rise to their moral responsibility, the fear of getting infected by the virus, hindered service by even the most dedicated health professionals. And then, on top of it, health care system has been locked down. Before COVID 19 arrived in full scale and intensity in Bangladesh, the 170 million people are already thrown into a major health crisis.
The first shock of denial of health services was Nazma Amin, a young Bangladeshi returnee (24 years) from Canada, who died due to gastrointestinal complications; her final hours were allegedly a blur of negligence of Dhaka Medical College Hospital (DMCH) doctors. It was in mid-March after the declaration of the first few cases of detection of Corona virus among the returnees from Italy – the country most infected by corona virus. She was not taken to the hospital with any symptoms of COVID 19, yet because she was a foreign returnee, the Nurses, Wardboys, doctors of DMCH were reluctant to provide services. Unfortunately they were not briefed enough about the COVID 19 symptoms, nor were equipped to test patients for virus. The medical staff did not have protective suits; so they allegedly refused to approach the patient until it was too late [ See Panic over coronavirus led to negligence, death: family of patient alleges, The Daily Star, March 16, 2020 ]. More incidents happened in the city with denial of services in and outside Dhaka.
The latest victim in Dhaka was Almas Uddin, an elderly person suffering from stroke, who was taken to 5 hospitals, was 16 hours on the Ambulance, without any success of getting treatment because he was also having fever and diarrhea. Hospitals refused to admit him with such symptoms. Finally one hospital in which he was admitted, denied services as they found signs of pneumonia. The reason was the fear of COVID 19 [ see , এম্বুলেন্সে ১৬ ঘণ্টায় ৬ হাসপাতালে ছোটাছুটি, অতঃপর বিনা চিকিৎসায় মৃত্যু Prothom Alo, 29 March, 2020 ]
In the meantime, news are pouring in from different districts that patients are not admitted into the hospitals with cold-cough-fever symptoms. No doctor, nurse or any healthcare provider are approaching them in fear. In Rajshahi medical College Hospital, a young man died with Corona virus symptoms being turned down to be admitted in different hospitals and finally died in RMCH on 28th March. [see Man with coronavirus symptoms dies at RMCH, Dhaka Tribune 29th March, 2020].
Centralizing, controlling and disseminating government approved structured information became the major task of the one and only Institute of Epidemiology, Disease Control and Research (IEDCR). On 29th March, the IEDCR declared there were no new case of COVID 19 detection and no new case of deaths reported in last two days. However, during the same time period, at least six people died with symptoms similar to that of COVID 19 in Khulna, Barishal, Rajshahi, Manikganj and in Lalmonirhat. No tests were done to determine contagion before their deaths. Three of these six patients were treated at isolation centers at hospitals in the districts and others were denied treatment [See ‘Six die with corona virus symptoms, no new case reported in Bangladesh’ The New Age Mar 29, 2020]. “No Test, No Corona” became the slogan that indicates the weakness of dependence on IEDCR tests only.
Why is such utter denial? Or is it the cruelty of the health professionals disjointed from Hippocratic Oath which many people would like to believe? It does not seem so, but it precisely demonstrates total unpreparedness and negligence at the high levels of the policy makers and strategists. No proper orientation to the health providers was available. No plan to warn and educate the people. Epidemic is not new to the people of Bangladesh. Over thousand of years they have dealt with small pox, cholera, malaria, Kalazar, etc. Previously combination of unavailability of modern science and health practice and the colonial administration hindered community efforts to deal with epidemics. But now science of health care has advanced but the post independent neo-colonial state couple with the destructive neo-liberal economic policy has become the major challenge for the people of the country. We hardly have any rudiments of Public Health, but health service is merely a commodity in the capitalist market. The multilateral and bilateral development partners should also be blamed for the present hopeless situation.
Destruction of Public Health by Neo-liberal Policy
Spectacular unpreparedness of the Bangladesh government manifests the destruction of public health bit by bit since the onset of neo-liberal economic policies adopted in the late 80’s, as a follow up to structural adjustment. Existing healthcare by the very nature of its being a commodity to be purchased from the market is anti-people. Very little can we expect to meet the challenges of COVID 19 pandemic. Less than 25% of the healthcare is provided through government hospitals at tertiary, secondary and primary level. There are less government health facilities than the private. Only 607 government hospitals compared to 5023 registered private hospitals and clinics and 10,675 registered private diagnostic centers. The number of hospital beds under government hospitals is only 49,414, while the private hospitals have 87,610; the total number of beds is 137,024 (DGHS, 2017). The private healthcare, which is mostly profit-oriented, provides about 70% of the high-cost health care services. The inequitable healthcare system of Bangladesh, for structural reason favors the wealthy and discriminates against the poor. Only “those who can pay, get the service”, is the rule in the private healthcare. It is very likely that most of the poor and disadvantaged patients may go undetected and unattended if COVID 19 epidemic soon hits Bangladesh. Will they simply die? Are we prepared for such catastrophe?
But even in the private hospitals, services were not available to patients trying to get treatment for ICU facilities. The private hospitals in the Dhaka city are empty of patients and doctors during the last week of March. The number of patient visits decreased from 500 to 34, and the number of doctors from 30 to 5 in one of the eye hospitals of the city. In the Diagnostic centers tests have reduced drastically, ultra-sonogram, echocardiogram, ETT etc are not done. The indoor patient care has also reduced to at least two-third in major private hospitals in the city. There must be numerous reported and unreported cases of such turning down of services to peoples’ health care needs [ see Bonikbarta, 29 March, 2020 “হাসপাতালগুলোর অর্ধেক শয্যাই ফাঁকা” and bdnews24.com 29 March, 2020 ‘হাসপাতাল খাঁ খাঁ’] .
It looks as if the only disease people are suffering from or may suffer from is corona virus (COVID 19) with symptoms of cold-cough-fever-respiratory problem etc. As if no other disease exists and no other disease needs treatment facilities. Before March 8, the date corona identified cases were officially declared by the government, Bangladesh had all other diseases mostly the non-communicable diseases (NCD). The burden on the health sector was mainly by the NCDs. According to Centre for Disease Control and Prevention (CDC), top 10 causes of death in Bangladesh include 1. Cancer 13%, 2. Lower Respiratory Infections 7%, 3. Chronic Obstructive Pulmonary Disease 7%, 4. Ischemic Heart Disease 6%, 5. Stroke 5% 6. Preterm Birth Complications 4%, 7. Tuberculosis 3%, 8. Neonatal Encephalopathy 3%, 9. Diabetes 3% and 10. Cirrhosis 3% [ Source: GBD CompareExternal, 2010] . But these diseases could not yet be brought under control and the services available for treatment is very inadequate.
The morbidity among the elderly population (64+ years) in Bangladesh is Arthritis (77%), high blood pressure (52%) diabetes (36%); this is according to the Health and Morbidity Status Survey- 2012, Bangladesh Bureau of Statistics, December 2013.
The normal cough-cold-fevers are common diseases among all age groups in the country. According to prevalence, fever (FUO) was highest in ranking and its prevalence per 1000 population was 52.2 and Acute Respiratory Infection ranked 8th out of 10 diseases with 4.9 per 1000 population [Health and Morbidity Status Survey 2012, BBS, GOB]. The health care system, from the community clinics, Upazilla health centers, district hospitals treat fever with symptoms only. The common people get outdoor treatment and get free medicine for fever. Very few are advised for further tests to diagnose the diseases. For acute respiratory infections, which may require support of oxygen, are referred to district or to Dhaka. Every day, hundreds of patients are coming in critical conditions to the Tertiary level hospitals such as Dhaka Medical College Hospital, BSMMU, Suhrawardy Hospitals, Cardiac hospital; the patients need ICU, CCU services and some even need Ventilators. Where have they gone? Are they all cured?
According to the Directorate General of Health Services (DGHS), there are 508 ICU beds in government hospitals and 737 ICU beds in private hospitals. This question also becomes very precarious when only 29 ICU beds have been prepared at Dhaka’s five hospitals to combat the pandemic, when elderly people infected with corona virus need ICU support the most. There is no ICU bed in any hospital outside Dhaka. [ see Bangladesh has only 29 ICU beds to fight coronavirus! The Business Standard, March 24, 2020] . Question is who will get access to these facilities?
The Health Minister Zahid Maleque informed the Press on 28th March that at present 500 medical ventilators are available, besides, more 450 ventilators will arrive within a short time. The ventilators, according to the minister are already distributed to different hospitals [ see “Corona tests being conducted at seven centres in country” The Daily Sun, 29th March, 2020]. But is the government coordinating between the private and government health facilities and declare that all the facilities will remain available to deal with COVID 19 and have same level of services? No.
What must we do immediately?
The unpreparedness of Bangladesh is being questioned by the public health experts as well as health activists since WHO declared COVID 19 as pandemic. The virtual absence of Public Health, neo-liberal market oriented promotion of health service available only for those who can pay, has already proved disastrous for the people. It is time that not only the Bangladesh government, but the multilateral and bilateral donors learn to be self-critical for their support to Bangladesh health sector. It is time that we review the past mistakes before it becomes too late.
Bangladesh has failed to successfully cross the first stage of controlling the pandemic due to non-recognition of the issue and systematic denial of infection and death tolls. Now that it has stepped into the second stage, it needs to show that once the number multiplies in large numbers, Bangladesh is able to handle it taking people along with the government. What Bangladesh needs immediately is the following:
1. Immediate efforts to earning trust and confidence of the people on the healthcare system. This can only be done by remaining transparent and honest to the people and stopping disinformation from the high levels.
2. Stigmatizing the patients with corona symptoms and particularly those coming from abroad must be stopped immediately. Panic and overreaction of the people is the disastrous consequence by singularly targeting people who are returning to their home.
3. Stop harassing people and arresting them for sharing information under various pre-text particularly by Digital Security Act for their legitimate concerns and protests in the name of socalled “Rumours”.
4. The most rational and urgent move could be commissioning the service of all the private hospital by the government and meet the challenge of the COVID 19 pandemic in unity with the existing government facilities as a national, central, well planned and strategic operation. It is a national crisis, and there is must explore innovative ways by which we can get the best of our public and private health care provisions.