IN A country where healthcare facilities are already inadequate, how are the government and private hospitals informally limiting their medical services? A largely unnoticed and sinister scale-down of outdoor, indoor and emergency services raises serious concern about people’s right to health, more so during the time of COVID-19 pandemic. This is a picture of the healthcare situation after the novel coronavirus outbreak in the country and it indicates serious violations of human rights. What should be our immediate course of action in this situation?
Systematic denial of health service
THE novel coronavirus outbreak is ravaging around the globe and in Bangladesh. So far, according to official accounts, 51 detected and five death cases were confirmed as of March 31, 2020. However, more people are reportedly dying of simple cold/fever/flu because of non-availability of treatment. These patients were not tested, but local level doctors suspected them of being infected by the coronavirus and therefore refused treatment. To maintain the celebratory national ambience for a grand-national occasion, the imminent danger of COVID-19 was underplayed and delayed even when Bangladesh got adequate time to prepare. According to public health experts and activists and many reports, the strategy of refusing test for people except for returnees from COVID-19 affected countries has created a crisis for patients seeking care in general and may lead to a disastrous situation. It also created a stigma against the returnees, the remittance earners of the country, and they were blamed for bringing the ‘misfortune’ to the country.
The government undertook no definitive plan to protect healthcare professionals, doctors, nurses, ward boys and other support staff. The unavailability of personal protection equipment became the major area 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. In what follows, it will not be mistaken to suggest that even before the outbreak of COVID-19 took a turn towards the worst in Bangladesh, people are already thrown into a major health crisis.
The first shock of denial of health services was Nazma Amin (24), a young Bangladeshi returnee from Canada, who died due to some gastrointestinal complications; her final hours were allegedly a blur of unintended negligence of Dhaka Medical College Hospital doctors. It was in mid-March after the declaration of the first few cases of coronavirus among the returnees from Italy — the country most affected by the coronavirus. She was not taken to the hospital without any symptoms of COVID-19, yet because she was a foreign returnee, the nurses, ward boys and doctors of DMCH were reluctant to provide services. Unfortunately, they were not briefed adequately about the COVID-19 symptoms, nor were they equipped to test patients for the virus. The medical staff did not have protective suits; so they allegedly refused to approach the patient until it was too late. Since then, more similar incidents took place in and outside Dhaka.
The latest victim in Dhaka was Almas Uddin, an elderly person suffering from a stroke. He was taken to five hospitals, and spent 16 hours in an ambulance, without being able to get the health care needed for him because he was also having fever and diarrhoea. 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.
In the meantime, news are pouring in from different districts that patients are not being admitted into hospitals with cold/cough/fever symptoms. No doctor, nurse or any healthcare provider are approaching them in fear. A young man with coronavirus like symptoms were denied treatment in different hospitals and finally died in Rajshahi Medical College Hospital on March 28, 2020.
It appears that centralising, controlling and disseminating government approved structured information became the major task of the Institute of Epidemiology, Disease Control and Research. On March 29, the IEDCR declared that there were no new cases of COVID-19 and no new case of deaths reported in the past two days. However, during the same period, at least six people died with symptoms similar to that of COVID-19 in Khulna, Barishal, Rajshahi, Manikganj and Lalmonirhat. No tests were done to determine contagion before their deaths. Three of these six patients were treated at isolation centres in hospitals in the districts and others were denied treatment. The ‘no test, no corona’ policy indicates the weakness of the system during such a time when the COVID-19 test largely depends on the IEDCR.
Why such utter denial? Many thought that the apparent apathy of health professionals is the result of their Hippocratic Oath. It does not seem so; rather, it precisely demonstrates total unpreparedness and negligence at the high levels of policy makers and strategists. No proper orientation to healthcare providers was available. No plan was in place to warn and educate people. An epidemic is not new to the people of Bangladesh. History shows how they have dealt with small pox, cholera, malaria, Kalazar and more. Previously, a combination of factors including the unavailability of modern science, health practice and the colonial administration hindered community efforts to deal with epidemics. But now the science of health care has advanced, but the post-independent neo-colonial state coupled 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; whatever is there is merely a commodity in the capitalist market. The multilateral and bilateral development partners should also be blamed for the present situation.
Neo-liberal policy and destruction of public health
THE unpreparedness of Bangladesh government manifests the destruction of public health system bit by bit since the onset of neo-liberal economic policies adopted in the late 1980s. 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 from this system to meet the challenges of the COVID-19 pandemic. Less than 25 per cent of the health care is provided through government hospitals at tertiary, secondary and primary level. Private sectors have taken over the health sector with only 607 government hospitals against 5023 registered private hospitals and clinics and 10,675 registered private diagnostic centres. The number of hospital beds under government hospitals is only 49,414, while the private hospitals have 87,610 taking the total number of beds to 137,024 (DGHS, 2017). The private health care, which is mostly profit-oriented, provides about 70 per cent of the high-cost health care services. The inequitable healthcare system of Bangladesh favours the wealthy and discriminates against the poor. ‘Only those who can pay get the service’ is generally the rule in the private healthcare system. It is very likely that most of the poor and disadvantaged patients will go undetected and unattended, if and when COVID-19 takes an epidemic turn in Bangladesh. Will they simply die?
But even in the private hospitals, services were not available to patients trying to get treatment in intensive care units. By the last week of March, private hospitals in Dhaka are unusually vacant with very few patients and doctors. In one of the eye hospitals of the city, the number of patient visits decreased from 500 to 34, and the number of attending doctors decreased from 30 to five. In diagnostic centres, tests have reduced drastically; ultra-sonogram, echocardiogram, ETT, etc are reportedly not offered. 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 informal closing of services for the people who need health care (bdnews24.com, March 29, 2020)
It appears as if the only disease people are suffering from or may suffer from is COVID-19. As if no other disease exists and no other disease needs to be treated. Up until March 8, the date when the first case of COVID-19 was officially confirmed by the government, Bangladesh had all other diseases, mostly the non-communicable diseases. According to the Centres for Disease Control and Prevention, the top 10 causes of death in Bangladesh include: (1) cancer 13 per cent; (2) lower respiratory infections 7 per cent; (3) chronic obstructive pulmonary disease 7 per cent; (4) ischemic heart disease 6 per cent; (5) stroke 5 per cent; (6) preterm birth complications 4 per cent; (7) tuberculosis 3 per cent; (8) neonatal encephalopathy 3 per cent; (9) Diabetes 3 per cent; and (10) Cirrhosis 3 per cent (GBD CompareExternal, 2010) . But these diseases could not yet be brought under control and the services available for treatment is very inadequate.
According to the Health and Morbidity Status Survey 2012, the morbidity among the elderly population (64+ years) in Bangladesh is arthritis (77 per cent), high blood pressure (52 per cent) diabetes (36 per cent). 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 healthcare system, from community clinics, upazila health centres to 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 the district hospitals or to Dhaka. Every day, hundreds of patients come in critical conditions to the tertiary level hospitals such as Dhaka Medical College Hospital, Bangabandhu Sheikh Mujib Medical University, Suhrawardy Hospitals, etc. They need cardiac care, services offered in intensive units, oxygen and ventilator supports. Where have they gone? Are they all cured?
The health minister Zahid Maleque informed the press on March 28 that at present 500 medical ventilators are available, and 450 more ventilators will arrive within a short time. The ventilators, according to the minister, are already distributed to different hospitals. But is the government coordinating between the private and government health facilities and declaring that all the facilities will remain available to treat COVID-19 patients? The answer is ‘no’.
What must we do immediately?
THE unpreparedness of Bangladesh is being questioned by public health experts as well as health activists since the World Health Organisation declared COVID-19 as a pandemic. In the virtual absence of a public healthcare system, neo-liberal market-oriented health services are available only for those who can pay, and it has already proved disastrous for the people. It is time that not only the Bangladesh government but also the multilateral and bilateral donors learned to be self-critical of their support to the Bangladesh health sector. It is time we reviewed past mistakes before it is too late.
From the news reports and information shared in social media by citizens, it seems that Bangladesh has failed to take the steps needed in the first stage to control the spread of the virus due to non-recognition of the scale of the outbreak and systematic denial of infection and death tolls. Now that it has reached the second stage, it needs to show that once the number multiplies, as is predicted by health experts and activists, Bangladesh is fully prepared to handle it. In the current situation, to prevent the outbreak from taking a turn towards the worst, the government must take the following steps immediately:
1. Immediate efforts to earn the trust and confidence of people in the healthcare system are needed. This can only be done by being transparent to the people and putting an immediate stop to the disinformation from the high levels
2. Stigmatising the patients with coronavirus like symptoms and particularly those coming from abroad must be stopped immediately. The panic and overreaction of people are the disastrous consequences of the government’s actions as it has singularly targeted people who returned to their home from abroad.
3. Stop harassing people and arresting them for expressing their legitimate concern during this time of crisis under the Digital Security Act in the name of preventing ‘rumours’.
4. The most rational and urgent move by the government now could be to commission the services of all private hospitals, along with public hospitals, in their full capacities to meet the challenge of the COVID-19 pandemic as part of a well-planned and strategic national operation.
It is a national crisis, and we must explore innovative ways to provide the best of our public and private healthcare services for the people of Bangladesh.
Farida Akhter is the executive director of UBINIG and organiser of Nayakrishi Andolon.
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