In Bangladesh, COVID-19 threatens to cause a humanitarian crisis

Dhaka’s streets are eerily empty. When 10 million rickshaw drivers, day labourers, factory workers, maids and others raced to get home before the start of the shutdown - announced by the government on 26 March - the city became unnaturally quiet.

Dhaka is usually full of the sounds of interaction, energy, and a growing economy. These are the sounds of people earning money; people who were able to get by financially.

Where are they now? What will they eat? How long can a rickshaw puller like Shumi in Rajshahi, whose family of five subsists on what she can bring home at the end of the day, after she has paid a 350 taka ($4.10) guarantee to the rickshaw owner?

According to World Bank data, only 15% of Bangladesh’s population makes more than 500 taka ($5.90) a day. They can meet their daily expenses, send their children to school, and hope that they reserve enough for an emergency health crisis. Most villagers depend on remittances from the cities or abroad. But because this is a global crisis, people everywhere are out of work. Income has stopped.

The US government is now encouraging physical distancing until the end of April. Approximately 75% of US workers have access to paid sick leave, and close to 90% have health insurance. Almost one-third of people could work effectively from home. And yet we still see that, despite all of these forms of social support and benefits, many people are struggling financially with the consequences of COVID-19 policies.

In Bangladesh - where over 90% of workers are in the informal sector, health insurance is a luxury, and most homes don’t have any sort of internet connectivity - how much more devastating would these policies be here? How many workers making 500 taka a day can work from home?

For Bangladesh, let’s admit that COVID-19 is a humanitarian crisis with a public health dimension. If large-scale physical distancing is required, we must find ways to mitigate the economic shock that will bring the majority of the country into food insecurity within weeks. The urban poor, who live off their daily wages, will have to skip meals. Let’s find ways to keep people safe that also protect their livelihoods. If they absolutely must stay home, we will need to provide food or emergency cash transfers. Assuming that mobile money providers are able to keep their agents active during this time, we have a financial system that goes deep into the villages and could deliver money to almost every household.

While there are important lessons to be learned from China, South Korea, Italy and other countries who are deeper into their COVID-19 response than we are, we should also question how much of their policies could be imported here. China’s health expenditure per capita is 10 times that of Bangladesh; Italy’s is eight times higher than China’s.

It doesn’t stop there. People who are staying at home will connect to the world through their smartphones - buying groceries, sending money to loved ones or video chatting with friends to stay mentally positive. The data from smartphones - location information in particular - has proven invaluable in contact tracing. In South Korea, a website that tracks the locations of newly identified cases enables people to see if they have been exposed at the mall or the movies, and to seek testing. Today in China, people get a red, green or yellow message on their phone that lets them know whether they should prepare to leave their home and go to work, based on the latest COVID surveillance data. Contrast this with Bangladesh, where many people struggle to understand text messages, and a recent phone-based COVID-19 survey led to widespread confusion.

We can seek inspiration from other countries' models, but we should also recognize that many mitigation strategies may be out of our reach. We should also realise - soberingly - that our public healthcare system is already overburdened and that the curve, as is, very skewed and not flattened. According to World Bank data, Bangaldesh has 8 hospital beds for every 10,000 people; by way of comparison, the US has 29 beds per 10,000 people while China has 42.

It gets worse. The country's entire public health system has 432 ICU beds, only 110 of which are outside the capital Dhaka. The private healthcare sector adds another 737 - and this is for a population of 170 million. Italy has 4.1 doctors on average per 1,000 people whereas Bangladesh has 0.5; that is based on official numbers, and a significant chunk of these doctors are either abroad or not practicing. At Dhaka’s medical college and hospital, the largest government medical facility in the country, over 500 patients seek critical care monthly, and more than 400 are turned away due to lack of capacity.

We need to think hard about an appropriate public response in a place as densely populated as Bangladesh, where most families’ ability to eat depends on daily wages and 87% of employment is generated by the informal sector. The average household in Bangladesh has more than five members, and usually includes three generations. Families share one latrine and more than 80% of households living in slums share a water source with five or more other households. There is no way to separate the old and the young; in other words, to separate the productive adults from those whose age makes them more vulnerable to serious illness and death. To practice the social distancing norms that most Western countries have relied on to reduce transmission is proving to be culturally completely impossible here. How do you stock up on 30-day supplies when you can only buy a few days’ worth of food? What will you do after that food runs out if your income has been cut off?

While I am worried, I also have endless faith in Bangladesh’s ability to rise in a moment of crisis. Even when outsiders see us as a basket case, we see an innovative path forward. When global health experts said that Bengali mothers couldn’t make oral rehydration solution at home and we’d have to import packets of premade solution, which were heavy and difficult to transport to rural villages given the communications infrastructure in the 1980s, we taught families how to prepare 'lobon-gur' (a mixture of local salt and unrefined sugar) and child mortality plunged. When people in villages were dying of tuberculosis because the hospitals were too far away, we found ways to bring testing and treatment to the community level.

COVID-19 is new and different in important ways, but we are home to premiere public health experts and institutions. We have one of the world’s best networks of community health workers, a rich history of public-private partnerships in emergencies, and communities with incredible levels of resilience.

We have weathered cyclones, floods, and so much more. Let’s not underestimate our own ability to find the best way forward in this crisis, to find the best in ourselves and make sure that we help each other survive this crisis.