Dipak Mitra on Defence Against the COVID-19 Pandemic

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Our government is fearing a second wave of infections during the winter season. Keeping everything in mind, how can we best prepare against it?
To be honest,whether it will be identified as the second wave or not has become irrelevant. More importantly, we have to understand that we are in the middle of a pandemic which can get worse in the winter. The speculation has prompted us to look for ways to avert the situation. Interestingly, public health measures remain the same; there has been no recent discovery to suggest otherwise. Furthermore, we can put the measures in use more confidently, as our knowledge of the pandemic and its nature has grown significantly.
At the individual level, we have to continue wearing masks, keeping our hands clean and maintain social distancing. I understand that the quest for economic survival has made social distancing very challenging in Bangladesh, avoiding non-essential social gatherings can also play a crucial role in preventing the spread of the virus. We have to keep adjusting our lifestyles to minimise the risk of getting infected. More importantly, we have to maintain case isolation; identified patients must be isolated to minimise transmission of the virus.
Unfortunately, case detection is much more difficult in the case of COVID-19. Unlike the common cold, the primary symptom of the disease (loss of taste and smell) can only be felt by the patient. Therefore, awareness must be present at an individual level. We also have to address the process of quarantining and its constraints in our country. Realistically, restricting community contact is extremely challenging for Bangladesh due to socio-economic and infrastructural constraints. However, minimising family contact can be achieved by isolating the infected person while the rest of the family members remain inside their home for a specific period.
Globally, the efforts against the spread of the pandemic have been significantly disrupted by misinformation, especially regarding wearing a mask. We need to remove any misconceptions and reassure the public that wearing a mask is the best defence against the COVID-19 pandemic until a vaccine is invented. The government has to implement a practical mandate which will be convenient for the general public and failure to comply with it will have legal implications.

Do you think we need another lockdown?
We have to decide on the necessity of another lockdown by evaluating advanced modelling. Bangladesh might not require a complete lockdown to minimise the infection rate. The nature of transmission has been different throughout the world. The rate has varied significantly across various districts in Bangladesh.
Ideally, we might require area-specific lockdowns. However, the government has to keep in mind that lockdown comes with high economic costs. So, any such measures must be accurately evaluated and efficiently implemented.
The transmission rate of a viral disease depends on three factors. They are Transmission Probability (the rate at which it spreads), how long the patient remains infectious (for COVID-19, the period is five to six days) and finally the Contact Rate. A necessity in reducing the contact rate will prompt a lockdown. I believe we will not require a complete lockdown and to be honest, it is not practical considering the constraints.

Our government has already assured the mass availability of the COVID-19 vaccine as soon as it is available. What kind of policy and strategy will enable them to deliver on that promise? Are the national commissions adequately competent and equipped to ensure its proper distribution?
It is a very important question because we have become psychologically dependent on the availability of a vaccine. However, we must remember that making a vaccine available for wider public use is time-consuming. It needs to pass specific safety and efficacy standards before being permitted for broader use. Therefore, there should not be any pressure to accelerate the process and should be left exclusively to scientists.
Considering the magnitude of its importance, the government needs to focus on the capacity building before the availability of a vaccine. Different countries around the world have varying strategies to access the vaccine, which ranges from diplomacy to intimidation.
Even though we cannot produce a vaccine, I am confident our government is competent to conduct trails and mass distribution by itself. Our effort will be well supported by our development partners and the Global Alliance for Vaccines and Immunisation (GAVI) which are a partner of.
On a national level, we have to have a high-level technical committee; if required, it should be devised exclusively for vaccine distribution. The government should expand its lobbying efforts to raise funds from international agencies. We have already been promised funds of the Asian Development Bank (ADB) and GAVI. The urgency to collect funds must persist before the confirmation of the vaccine because the situation might drastically change afterwards.
There needs to be proper planning in place for its distribution when the vaccine is available. As a lot of it will not be available at the initial stage, so there needs to be a proper distribution strategy in place before it arrives. The priority list might be based on age, gender or region basis. It is essential to understand that those who recovered from COVID-19 will not require a vaccine as long as the antibody lasts. So, we might require an antibody test to ensure vaccines are not wasted. Additionally, the government needs to be aware of the adequate storage conditions of the vaccine and provide capacity building accordingly. Due to the multidimensional challenges of the situation, a robust technical committee focused on the vaccine distribution will ensure effective distribution of the vaccine in Bangladesh.
As the lockdown restrictions have been withdrawn, we see an increasing number of people in our streets. Also, the number of deaths and infections have become steady in recent times. Are these indications that we are moving towards herd immunity?
Without a comprehensive antibody test, it is impossible to claim that we have achieved herd immunity of any magnitude, which has not yet been allowed by the government. I think the authorities should allow antibody testing for a research purpose; it can provide valuable insights on tackling the pandemic and enhance our understanding of the current situation.
However, herd immunity can be very quickly achieved by a combination of mask usage and vaccine injection. Currently, wearing a mast is the most effective measure to protect against the spread of the pandemic. If we can strictly follow mask mandates, proper hand hygiene and social distancing regulations, we can achieve herd immunity by vaccinating only about 30% of our population.
We (health experts/government) have failed to engage and enlighten the general population about the benefits of maintaining the safety regulations, which has led to their passive attitude towards the measures.

Moving on from the pandemic to our public health sector, what kind of policy reforms are necessary to recuperate our health sector?
Health sector reform is a continuous process; it is mandatory to ensure a functioning public health sector. The process ranges from minor reforms to overhauling of the sector. Right now, it is evident that we require a complete overhaul.
The health sector is everybody’s business; its effects are not limited to a few people. Primarily, the sector can be divided between medicine and public health.
Over the last five decades, Bangladesh’s life expectancy has increased from forty to seventy years; the public health sector contributed 90% to this achievement and the rest by clinical health. I am not suggesting that clinical health is less important, but it has more impacts on increasing the life expectancy of a population.
We need to devise a balanced health system where the two branches will have equal contribution to the sector. The reform should be conducted according to the designed plan. It has to be inclusive, practical and carried by experts of our country exclusively. Most importantly, there needs to be the intent and political commitment to make significant changes.

We know that bureaucrats play a significant role in the health sector’s activities. How can we ensure that public health experts play a more significant role in the sector?
Historically, Bangladesh has a lot of public health success stories where public health experts had pivotal roles to play. Things have been different this time around. The participation of public health experts have declined over the past decade, and it is the result of overall failures, including the experts themselves. They are required to maintain visibility for the interest of the general people. Our media deserves a lot of credit for the way they have covered the pandemic and focused on expert opinions. However, the underlying fact remains that the health experts have worked towards national and global recognition.

According to a survey, only 5% of Upazila health employees have a degree in public health. How can we increase the competency level of public health employees at that level?
In Bangladesh, it is not mandatory for public health employees to undergo public health training, unlike many developed countries. Bangladesh government employees go through foundation training before joining their positions. Incorporating public health training in that course will be beneficial for all the stakeholders in the sector.
In the medium term, we can facilitate public health training for everyone. In the long term, we can redesign our MBBS syllabus to accommodate public health in place of community medicine. The change in curriculum and employing capable educators should happen concurrently. The best part of public health is that everyone can play a role in its advancement irrespective of their profession. Public health education has improved in our country over the last decade, but currently, there is no central body to guide its graduates. There is an urgent need to establish a Public Health Accreditation Council to ensure greater professional acceptability of public health professionals.

The patient to doctors/health workers ratio in Bangladesh is very high. How can we invest resources in the sector to efficiently address this problem?
It is a very complicated topic; resource building will not happen overnight. We have to achieve that on a phase by phase basis. First of all, we require commitment towards this goal. It starts with identifying the challenges and devising a plan accordingly.
Moreover, we have a high concentration of doctors/health workers in cities. Therefore, we need a policy to decentralise the health care system.
We also have to focus on improving the quality of our private medical colleges. The standard of quality should be uncompromising when it comes to medical professionals. Therefore, private universities and medical colleges should not be judged on similar criteria.
Most importantly, the private sector plays a significant role in providing health services to our population. More people take private services compared to government counterparts. There is a visible conflict of interest between the two-sectors when it comes to health professionals, and it has to be sorted out. It will enable the private sector to operate with much more autonomy.

We have been witnessing a sharp rise in mental health cases and violent crimes in our society. From that perspective, what should be the role of public health in dealing with the rise in mental health issues?
Mental health is a critical topic and should be prioritised in ensuring better public health. As I am not an expert, I am talking from a layman’s perspective regarding violent crimes. We need to ensure proper mental evaluation of convicted offenders in our system. Mental health is an ignored topic in our society; even patients who are physically suffering are likely to develop mental health issues. Mental wellbeing of patients should be prioritised in our hospitals. Every human being in the world suffers from some form of mental issues that he/she needs to overcome. However, to ensure it does not become an impediment to everyday life, early diagnosis is essential.

In Bangladesh, numerous stakeholders are working in the health sector, especially NGO(s) generating a lot of data which we have no mechanism to use. How can we better use data to improve our healthcare system?
Globally, two terms that are being widely used in public health are big data and health informatics. Health informatics relates to the information generated when service is provided to a patient. Gathering primary data is very costly and time-consuming, on the other hand, we are automatically getting data in the form of big data and informatics, which can be used to improve services. It will allow us to make data-driven decisions. We need some technological overhaul to improve the quality of data and expertise to ensure its efficient use.

What is your take on the current public health education of the country?
Public health education has improved in our country over the last decade, but currently, there is no central body to guide its graduates. Numerous private universities are offering degrees in public health which are compatible with global standards.
There is an urgent need to establish a Public Health Accreditation Council to ensure greater professional acceptability of public health professionals.

To be honest,whether it will be identified as the second wave or not has become irrelevant. More importantly, we have to understand that we are in the middle of a pandemic which can get worse in the winter. The speculation has prompted us to look for ways to avert the situation. Interestingly, public health measures remain the same; there has been no recent discovery to suggest otherwise. Furthermore, we can put the measures in use more confidently, as our knowledge of the pandemic and its nature has grown significantly.
At the individual level, we have to continue wearing masks, keeping our hands clean and maintain social distancing. I understand that the quest for economic survival has made social distancing very challenging in Bangladesh, avoiding non-essential social gatherings can also play a crucial role in preventing the spread of the virus. We have to keep adjusting our lifestyles to minimise the risk of getting infected. More importantly, we have to maintain case isolation; identified patients must be isolated to minimise transmission of the virus.
Unfortunately, case detection is much more difficult in the case of COVID-19. Unlike the common cold, the primary symptom of the disease (loss of taste and smell) can only be felt by the patient. Therefore, awareness must be present at an individual level. We also have to address the process of quarantining and its constraints in our country. Realistically, restricting community contact is extremely challenging for Bangladesh due to socio-economic and infrastructural constraints. However, minimising family contact can be achieved by isolating the infected person while the rest of the family members remain inside their home for a specific period.
Globally, the efforts against the spread of the pandemic have been significantly disrupted by misinformation, especially regarding wearing a mask. We need to remove any misconceptions and reassure the public that wearing a mask is the best defence against the COVID-19 pandemic until a vaccine is invented. The government has to implement a practical mandate which will be convenient for the general public and failure to comply with it will have legal implications.

Do you think we need another lockdown?
We have to decide on the necessity of another lockdown by evaluating advanced modelling. Bangladesh might not require a complete lockdown to minimise the infection rate. The nature of transmission has been different throughout the world. The rate has varied significantly across various districts in Bangladesh.
Ideally, we might require area-specific lockdowns. However, the government has to keep in mind that lockdown comes with high economic costs. So, any such measures must be accurately evaluated and efficiently implemented.
The transmission rate of a viral disease depends on three factors. They are Transmission Probability (the rate at which it spreads), how long the patient remains infectious (for COVID-19, the period is five to six days) and finally the Contact Rate. A necessity in reducing the contact rate will prompt a lockdown. I believe we will not require a complete lockdown and to be honest, it is not practical considering the constraints.

Our government has already assured the mass availability of the COVID-19 vaccine as soon as it is available. What kind of policy and strategy will enable them to deliver on that promise? Are the national commissions adequately competent and equipped to ensure its proper distribution?
It is a very important question because we have become psychologically dependent on the availability of a vaccine. However, we must remember that making a vaccine available for wider public use is time-consuming. It needs to pass specific safety and efficacy standards before being permitted for broader use. Therefore, there should not be any pressure to accelerate the process and should be left exclusively to scientists.
Considering the magnitude of its importance, the government needs to focus on the capacity building before the availability of a vaccine. Different countries around the world have varying strategies to access the vaccine, which ranges from diplomacy to intimidation.
Even though we cannot produce a vaccine, I am confident our government is competent to conduct trails and mass distribution by itself. Our effort will be well supported by our development partners and the Global Alliance for Vaccines and Immunisation (GAVI) which are a partner of.
On a national level, we have to have a high-level technical committee; if required, it should be devised exclusively for vaccine distribution. The government should expand its lobbying efforts to raise funds from international agencies. We have already been promised funds of the Asian Development Bank (ADB) and GAVI. The urgency to collect funds must persist before the confirmation of the vaccine because the situation might drastically change afterwards.
There needs to be proper planning in place for its distribution when the vaccine is available. As a lot of it will not be available at the initial stage, so there needs to be a proper distribution strategy in place before it arrives. The priority list might be based on age, gender or region basis. It is essential to understand that those who recovered from COVID-19 will not require a vaccine as long as the antibody lasts. So, we might require an antibody test to ensure vaccines are not wasted. Additionally, the government needs to be aware of the adequate storage conditions of the vaccine and provide capacity building accordingly. Due to the multidimensional challenges of the situation, a robust technical committee focused on the vaccine distribution will ensure effective distribution of the vaccine in Bangladesh.
As the lockdown restrictions have been withdrawn, we see an increasing number of people in our streets. Also, the number of deaths and infections have become steady in recent times. Are these indications that we are moving towards herd immunity?
Without a comprehensive antibody test, it is impossible to claim that we have achieved herd immunity of any magnitude, which has not yet been allowed by the government. I think the authorities should allow antibody testing for a research purpose; it can provide valuable insights on tackling the pandemic and enhance our understanding of the current situation.
However, herd immunity can be very quickly achieved by a combination of mask usage and vaccine injection. Currently, wearing a mast is the most effective measure to protect against the spread of the pandemic. If we can strictly follow mask mandates, proper hand hygiene and social distancing regulations, we can achieve herd immunity by vaccinating only about 30% of our population.
We (health experts/government) have failed to engage and enlighten the general population about the benefits of maintaining the safety regulations, which has led to their passive attitude towards the measures.

Moving on from the pandemic to our public health sector, what kind of policy reforms are necessary to recuperate our health sector?
Health sector reform is a continuous process; it is mandatory to ensure a functioning public health sector. The process ranges from minor reforms to overhauling of the sector. Right now, it is evident that we require a complete overhaul.
The health sector is everybody’s business; its effects are not limited to a few people. Primarily, the sector can be divided between medicine and public health.
Over the last five decades, Bangladesh’s life expectancy has increased from forty to seventy years; the public health sector contributed 90% to this achievement and the rest by clinical health. I am not suggesting that clinical health is less important, but it has more impacts on increasing the life expectancy of a population.
We need to devise a balanced health system where the two branches will have equal contribution to the sector. The reform should be conducted according to the designed plan. It has to be inclusive, practical and carried by experts of our country exclusively. Most importantly, there needs to be the intent and political commitment to make significant changes.

We know that bureaucrats play a significant role in the health sector’s activities. How can we ensure that public health experts play a more significant role in the sector?
Historically, Bangladesh has a lot of public health success stories where public health experts had pivotal roles to play. Things have been different this time around. The participation of public health experts have declined over the past decade, and it is the result of overall failures, including the experts themselves. They are required to maintain visibility for the interest of the general people. Our media deserves a lot of credit for the way they have covered the pandemic and focused on expert opinions. However, the underlying fact remains that the health experts have worked towards national and global recognition.

According to a survey, only 5% of Upazila health employees have a degree in public health. How can we increase the competency level of public health employees at that level?
In Bangladesh, it is not mandatory for public health employees to undergo public health training, unlike many developed countries. Bangladesh government employees go through foundation training before joining their positions. Incorporating public health training in that course will be beneficial for all the stakeholders in the sector.
In the medium term, we can facilitate public health training for everyone. In the long term, we can redesign our MBBS syllabus to accommodate public health in place of community medicine. The change in curriculum and employing capable educators should happen concurrently. The best part of public health is that everyone can play a role in its advancement irrespective of their profession. Public health education has improved in our country over the last decade, but currently, there is no central body to guide its graduates. There is an urgent need to establish a Public Health Accreditation Council to ensure greater professional acceptability of public health professionals.

The patient to doctors/health workers ratio in Bangladesh is very high. How can we invest resources in the sector to efficiently address this problem?
It is a very complicated topic; resource building will not happen overnight. We have to achieve that on a phase by phase basis. First of all, we require commitment towards this goal. It starts with identifying the challenges and devising a plan accordingly.
Moreover, we have a high concentration of doctors/health workers in cities. Therefore, we need a policy to decentralise the health care system.
We also have to focus on improving the quality of our private medical colleges. The standard of quality should be uncompromising when it comes to medical professionals. Therefore, private universities and medical colleges should not be judged on similar criteria.
Most importantly, the private sector plays a significant role in providing health services to our population. More people take private services compared to government counterparts. There is a visible conflict of interest between the two-sectors when it comes to health professionals, and it has to be sorted out. It will enable the private sector to operate with much more autonomy.

We have been witnessing a sharp rise in mental health cases and violent crimes in our society. From that perspective, what should be the role of public health in dealing with the rise in mental health issues?
Mental health is a critical topic and should be prioritised in ensuring better public health. As I am not an expert, I am talking from a layman’s perspective regarding violent crimes. We need to ensure proper mental evaluation of convicted offenders in our system. Mental health is an ignored topic in our society; even patients who are physically suffering are likely to develop mental health issues. Mental wellbeing of patients should be prioritised in our hospitals. Every human being in the world suffers from some form of mental issues that he/she needs to overcome. However, to ensure it does not become an impediment to everyday life, early diagnosis is essential.

In Bangladesh, numerous stakeholders are working in the health sector, especially NGO(s) generating a lot of data which we have no mechanism to use. How can we better use data to improve our healthcare system?
Globally, two terms that are being widely used in public health are big data and health informatics. Health informatics relates to the information generated when service is provided to a patient. Gathering primary data is very costly and time-consuming, on the other hand, we are automatically getting data in the form of big data and informatics, which can be used to improve services. It will allow us to make data-driven decisions. We need some technological overhaul to improve the quality of data and expertise to ensure its efficient use.

What is your take on the current public health education of the country?
Public health education has improved in our country over the last decade, but currently, there is no central body to guide its graduates. Numerous private universities are offering degrees in public health which are compatible with global standards.
There is an urgent need to establish a Public Health Accreditation Council to ensure greater professional acceptability of public health professionals.

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