A need for transparency

We are still in the first month of the novel coronavirus in Bangladesh – the one-month anniversary of our official detection of the virus to be solemnly acknowledge someday next week. The Institute for Epidemiology, Disease Control and Research (IEDCR) with the Directorate General of Health Services (DGHS) pronounced on 8 March that it had detected the coronavirus for the first time in three patients in the country, all in the same location. The news came a bit suddenly amid prior daily reassurances that we did not have any infections or that we were even needed to test people for it. Bangladesh was at least ahead of one country in the region – Myanmar – in detecting the first case.

The lull in our consciousness was a direct result of watching the world being battered in front of our eyes, while being reassured that we were still safe. Though our infection declaration did ensue after a good period of media reassurance from the Government – a slow drip over almost two months, that unnecessarily repeated the WHO statistics and detailed how our bureaucrats were being watchful of the global incidence of the disease with little clarity about how Bangladesh was gearing up to respond to the inevitable infection. No instructions for ramping up the capacity of hospitals, clinics and primary healthcare centres and no targeted directives for doctors or pharmaceuticals were given. Until the end of March, the average informed citizen remained unable to answer which hospitals were assigned for a coronavirus emergency and to this day, most people believe that they can go to any of the testing centres to get tested. The IEDCR, or the Foreign Ministry – but rarely the Health Ministry – made cautious and calculated remarks to the media about the state of affairs including … well let’s see … mostly matters abroad – the number of people outside the country requesting repatriation, the complexity of the flights, the foreseen difficulty in regional trade should the threat truly escalate, and of course how perfectly prepared our land, sea and air ports were, in order to identify any Covid-19 patients entering the country. 

We supposedly have sufficient thermal scanners, our hospitals are ready to receive patients with the relevant symptoms, that there are double-digit number of facilities that can carry out testing, that we have the necessary equipment and protocol in place, and the personnel are ready to handle every exigency. Everything appeared perfectly managed and handled on the face of it, but the truth of the matter is, the information does not stand scrutiny. The health agencies conducted no review of existing capacity, undertook no modelling of the infection, issued no protocols about handling patients and any subsequent mortality, and did not allocate any emergency budget for the health response and did not even project how lives and livelihoods would be affected.

The international spread of the virus began in mid January when it was still limited to a few countries and the affected persons were in the order of a few thousand. Towards end January, coronavirus news started to hurtle in and its stories were in the papers every day. There were troubling international stories of the epidemic, which in our papers, was wrapped up with reassuring words about how we were infection free. The coronavirus was a legitimate spectre looming in the horizon but no warnings with sufficient gravity was issued, and no specific entity was called upon to prepare. Day after day passed as the Government organs loaded the press with irrelevant data of how much they were accomplishing, how much work they were doing to prepare, as did the hardly-official entity of the PM’s son … but this nation’s policy-makers could not craft any worthwhile guidelines for either ‘containment’ or ‘mitigation’ – be it for the frontline institutions (hospitals, clinics and other public health infrastructure), the people (individuals, families, teachers and employers) or for the economy (small and large businesses, industries, banks, utility and service providers and worst of all the transportation sector). I am certain that the PM’s close affiliates could not even predict the scale of this crisis, and they prevented the technical entities from playing their independent roles. We are unable to find a single clear, consistent, or complete set of directives for any group of persons to respond to a pandemic.

I am able to claim this because pandemic preparation means assessing the nature and scope of the threat, assigning responsibilities to respective offices, undertaking a thorough evaluation of the cost of the disease’s onset, estimating the cost of the response, calculating the possible duration and depth of the virus’ recourse in the community i.e. its intensity, the required emergency budget, possible sharing of the burden with the private sector and individuals, and most importantly – informing people to educate them and not simply ordering them at non-sensical intervals with incoherent directives. It became newly evident that timeliness, professionalism and accountability were not defining ethics of this government.

While the whole world braced for the virus in a manner defined by the epidemiology tool ‘coronavirus curve’ predicting how many infections could occur and when that would ‘peak’, Bangladesh decided it did not need to prepare for the peak. Our high-ups deliberately and vehemently rejected that science by barring the only reliable method for serviceable data collection – testing. While no one among the policymakers were able to interpret the epidemiological implications or project the ‘peak’, they nonetheless discredited the experts and refused to allow free testing of everyone with symptoms by introducing a false criterion of having come into contact with foreign returnees. While that could have been a valid criterion in the application of air-tight containment measures but we had long since passed that point when returnees entered the country without screening. We were in the phase of community transmissions that IEDCR conveniently circumvented or denied. Disease experts and disaster early responders sat aside while government machinery churned out sporadic statistics that showed that this is not a crisis in Bangladesh. We got a national holiday with no clear instructions, when what we should have had was a lockdown.

What I regret most is that the government, does not trust or rely on the people to help mitigate the crisis. It feels that it does not need to share information with the people transparently, and that the better option for government’s survival is to provide as little information as possible, to leave matters hazy enough that the collective population and not just civil society could ask questions. People are concerned, confused and exhausted of listening to reports of how the virus is doing all over the world but not being shared a complete plan of how we will deal with it even three months after the first cases appeared. Given that this is probably going to be the greatest threat of this century, it is laughable to suggest that the government did not know that it was coming, and even more laughable to imagine that the government does not believe it needs the help of its people to respond to the virus’ spread, and protect our lives and livelihoods.

Recurring political considerations got in the way of transparent communication and response to the pandemic. In January when it was time for adopting containment measures, Dhaka had to organise mayor elections. At the same time when Bangladeshis were repatriating from China, unfettered, we were busy counting votes. On 31 January, a sick Bangladeshi returning from China even languished at the airport overnight before being assisted to the hospital the following day. Since the first news of the virus until 2 February, some seven thousand persons returned from China, until further returns were brought under controlled oversight, plus on-arrival visas were Chinese persons were stopped. What happened to these persons who have returned to their communities? We do not know but hope that the government does. Until the second week of February, thermal scanners at our three international airports were not working properly and were sporadically used. We were being reassured that the Government had everything under control however there was disagreement in the number of arrivals through the airport, between newly formed ‘IEDCR Control Room’ and the ‘Health Emergency Operations Centre’ that usually activates under these circumstances. Thereafter, the IEDCR was solely tasked with the responsibility of public speaking, which is different from other crises; and if there were individuals with Covid-19 symptoms identified during February which there is every reason to believe that there were, then it was hidden from the public.

The principle that should have been practiced here with citizens was transparency, engagement and full disclosure, whereas our leaders freely chose to ignore those and instead practiced aloofness, cursory briefings and information suppression - they were waiting to see how badly it affects us before designing their response. If you wait for ‘real’ data for any country, then by the time it would become available, it would be just too late to save anyone and this is why modelling is used. We have the data from worldwide and we have very credible models to depend on, which the most advanced nations are relying on to design their contingency planning and here we were, waiting for the influx and in the meantime concealing data to ‘lower the curve’ and imagining foolishly that the delays and distractions are not going to catch up with us. This will not only prove politically counterproductive but is also morally repugnant as it has put the lives of each one of us in danger.

From later developments it becomes clear that information was available, but for reasons deemed necessary by the government, it was being rationed and curated. In order to be able to do so, a chokehold was placed on the ability of diagnostic centres to collect samples for testing. It is true that the IEDCR is the national research facility for diseases but there are other competent and excellent facilities that are able to reliably collect and test virus samples but they are not allowed to do so. Is it incorrectness? What would have been the great loss of having some alleged false positives in exchange for being able to provide the right kind of treatment for this deadly virus earlier, and with better coverage? If it is not the efficacy, then why was IEDCR the only body allowed to collect blood and mucus samples? Well it was done simply to allow the government to control the narrative of this infection. The government needed to be the arbiter of who was infected and how wide was the scope of the threat each patient projected – it was decided early that only a few in power should define the curve. But not only that – they also needed to prioritise which events occupied the national psyche especially because the birth centenary of our great liberator was coming up. A few of his children left to die or to infect others, was a reasonable price to pay for the noble undertaking of his birthday countdown. The Ministries did not talk with each other, and everyone kept themselves busy preparing for the birth centenary. Valuable time was lost while the Government dallied in February and March, which could have been utilised to curb community transmission of the disease.

Since late January, the novel coronavirus’ threat to Bangladesh was considered to be limited to returnees from China, however clear instructions for isolation or quarantine were neither issued nor practiced even by the smallest risk cluster. Despite the constant updates to the local press about the preparations that were sufficiently underway, there was no measure uniformly applied to simply screen arrivals at the port and separate the identified risks. Ministries did not formulate any plans, the economy was not prepared to be shielded, it was sheer luck that there was sufficient food stockpile. The first wave of thousands of returnees from China arrived without screening; where are those people now and have their communities quarantined them? That was our first trigger for community spread. For this, we cannot blame individuals for spreading the disease but must hold the public health system that the individual is contained within, responsible.

Through February, the media was made to focus on one batch return of 360 persons from China and deliberated in great detail about the possible underlying risk of allowing that. In the meantime, two returnees who were already admitted in Chittagong with the Covid-19 symptoms were not highlighted. When the 360 finally returned from China, we were told that 302 individuals were unaffected … so where were the remaining 50 and how were they? No persons were declared to be identified with the virus and we as the gullible public accepted that.

After this successfully managed return, regular news of the virus awareness fell away as there were important national events – the Dhaka City Corporation mayor elections, followed by the under-19 cricket World Cup victory, and then the preparations for the hyper-budgeted birth centenary of the Father of the Nation, and lastly the plans Independence Day, so with all these, the disease was sidelined conveniently so that numbers would not have to be counted.

No consistent effort was made to educate the population for prevention and awareness, and limiting, curating and rationing information were maintained as the government approach.

There were still no directives for hospitals and clinics, no emergency budget allocations, and no assessment of the overall threat and risk for lives, livelihoods and even our economy. The only message that people received from the Government was they were preparing hard. This is laughable because the ones that need to prepare are the people – the patients, the carers and the doctors, received no complete communication about handling of the disease. In the absence of concrete recommended actions, the social media space became inundated with handwashing and sanitizing tutorials; the regime kept us busy while it worked to cover its tracks. In this time, no tracing of the seven thousand dispersed returnees, or the 361 recent returnees was made. The machinery was ‘prepared’ but it wasn’t moving in the right direction.

We do not yet have a comprehensive emergency response plan made by a competent authority. Neither the health or the disaster management and response arms of the Government made any master strategy, let alone a budget or scenario-based projections. Even if they did, they kept it well hidden from popular knowledge, and it is very surprising that none of the planning calls for an emergency medical preparedness of hospitals and doctors. People simply received updates from the media until the end of March. In a contrast to the absence of healthcare directives, the actions that the Government executed with sufficient alacrity were the arrest of five persons in the darkness of the night – for spreading misinformation on social media. Some of our institutions definitely operate with more speed than others in this crisis.

For the next entire month, from mid-February to mid-March no other preparations were spoken of, and news of the virus became thin. Some quarters were compelled to whisper that perhaps infected cases were being ‘managed’ so that the preparations for the birthday could be smoothly executed. In that interval, there was also the sudden exposure and sensational arrest of a criminal and money launderer Papia.

Gradually by 8 March when the global counter reached 100 countries, and Bangladesh as a regular trading partner of China was sailing along pretty breezily, we may have felt quite invincible but we had just been identified as a high-risk country. The WHO was also making uncomfortable sounds that most countries were not following recommended protocol. It was then at this definitive juncture, that Bangladesh pulled out the three identified cases out of its back pocket. Within a day of our carefully timed disclosure, the WHO declared a pandemic seeing countries not understanding the gravity of the situation.

It is most likely Bangladesh had to declare its three cases when it knew the pandemic declaration was forthcoming. No notifications were given prior, about the government (alone) collecting samples, as citizens were not asked to come forward, rather encouraged to stay at home even with symptoms and wait for sample collection with the inane assumption that all cases were in Dhaka. How did IEDCR imagine that it would catch all the infections without asking people to come forward? Is the government so widespread and so deeply informed? And how were we going to anticipate the broader situation without testing the maximum number of cases? And by which strategy were we to control the infection from spreading into communities when possible carriers without symptoms were omitted from testing?

The quick dot blot test proposed by others has been resisted by the Government throughout. There is such hesitation because of an inordinate fear of false positives but that could be allayed by mandating a second confirmatory test by IEDCR. These other institutions have been on the frontline of medical care and have provided services to larger volumes of people in everyday settings, whereas the IEDCR is only a specialised lab with a small handful of staff, who – no matter how specialised – cannot respond in the speed and breadth that BSMMU, icddr,b or GSK can. But the government has deliberately blocked these agencies from performing at the forefront of the disease response, which should burden it with criminal responsibility for each life that has been lost for the mishandling and slow response of this crisis. To mitigate the delays and increase testing in the fastest manner possible, all capable test sites should be allowed to collect samples to conduct the tests with any positive test perhaps meriting a re-confirmation from the IEDCR.

In this time, professionals and experts who were doing their work to gauge the scope of this crisis, got their hands were rapped by the government for being too progressive and causing panic because they did not have ‘correct information’. And the government certainly refused to share information with outside experts making it evident that it had planned all along to create its own infection curve. An academic that projected the epidemiological estimates of the spread of this virus was rapidly threatened by the government, and quickly abandoned by his institution.

It is sheer hubris by this government to underestimate this crisis. It’s assumption that it can handle the crisis by itself without the participation of the people – who by far is the most important element in mitigating this crisis – is deeply flawed. Whether the government wants to go down the ‘containment’, or the ‘mitigation’ route, it needs the support and compliance of its people. People right now are confused, are receiving haphazard sporadic directives, and are being presented daily with highly curated figures that are far from credible. This is directly leading to haphazard announcements of closure of schools and businesses, and random uninformed date changes and extensions. The economy is not only reeling from the external hit of reduced demand for our products, but also the internal impact of gross mismanagement. Even sitting in the month of April, Ministries of Commerce and Finance have not put forward a mitigation plan.

Information is not only being withheld from the people but also from the service providers. Moreover, the testing numbers are deliberately being undermined by imposing false criteria for exclusion, not tracing all the returnees since December, and not allowing all test centres to collect samples without the IEDCR’s high-handed endorsement. Although there was the glorified claim of 28 test centres last week, what was carefully suppressed is that none of these centres are allowed to collect samples. Our policymakers may not understand this but we are in a pandemic where reaction time is of essence. We may still be in the first month of the virus' detection here but it is wrong to think that we still have adequate time to craft a response. This is not the time for spin or bureaucratic hurdles, and attempting to mollify the public by rationing information is a mockery of everything that the government owes to its people.

Our government may insist that they are preparing heavily but the only thing that was properly prepared and served was the media exposure, for which we must applaud the concerned body. Based on the high quality and timing of the work, I suspect that it is not one of the Ministries or the PMO, but our office of intelligence itself.

The Health Ministry may protest that it has made adequate arrangements, but we can say from the simple knowledge of this country’s population, its resource base and its demographic density that it would not be enough. In the event that there is a major emergency, the thing that could save us as a group is the active, voluntary cooperation of the people. And for that, we need the responsible sharing of accurate, timely and complete information about who is getting infected, where, and how. People need support and guidance to undertake their own preventive measures to protect themselves, their families and their communities. Public health communication has always been a strength in this country and it should be revived in this crisis. The people are the government’s partner, not its adversary. They deserve to know their role in this crisis – even if you cannot guarantee them healthcare, doctors and ventilators, at least grant them the assurance of complete information.

Banani, Saturday 4 April 2020