Dr. Sabina Faiz Rashid, Dean and Professor, joined the James P Grant School of Public Health, at BRAC University, in 2004. She helped establish the Centre of Gender and Sexual and Reproductive Health and Rights at the School and, in 2013, co-founded the Centre on Urban Equity and Health, which generates research to influence policy and build awareness on urban issues. She received bachelor’s and master’s degrees in social anthropology from the Australian National University, Canberra, Australia, in 1992 and 1998, and in 2005 received a doctorate in medical anthropology and public health from the same institution. She has over 25 years of work experience in Bangladesh. Her areas of expertise are ethnographic and qualitative research, with a focus on urban populations, adolescents, and marginalized groups. She is particularly interested in examining the impact of structural and intersectional factors on the ability of these populations to realize their health and rights; to inform policy and practice.
What do you think are the public health measures that should be taken to combat the impending second wave of COVID attacks during the upcoming winter season?
We have had a clinician-led approach, a biomedical model of intervention to prevent and/or manage the coronavirus pandemic. In the context of Covid-19, the lockdown model was imported from a different context, from western or developed economies with stronger economic bases and better social safety nets for those in need. But for the future, is there a better way forward for countries such as Bangladesh with far greater resource constraints? The first cases of Covid-19 in Bangladesh were reported on 8th March, 2020, and as of October 03 2020, there were over 366,000 confirmed cases (WHO, 2020). To contain transmission, the state at the beginning announced a series of “holidays” from 26th March, 2020 which led to the closure of all public and private educational institutions, offices, transport services, factories, retail shops and so forth (Dhaka Tribune, 10 April, 2020) and people were asked to strictly stay at home. Without the option to work from home, the informal sector with over 50 million workers (87% of the workforce) was crippled and the economic disruption continues to threaten millions of livelihoods in Bangladesh.
Many segments of the Bangladesh population are vulnerable, yet the Covid-19 response on individual determinants of health, focusing on individual behavior with limited attention to the personal, socio-cultural, economic and structural factors is problematic. This approach prevents the most marginalized from following national recommendations/WHO guidelines. Practicing social distancing, washing of hands with soap, and staying at home are possible for the better off, but is a non-starter for a majority of the urban poor with 6 to 11 members crammed in one room within informal settlements, sharing irregular water supply, communal latrines, and cooking spaces. Communication messaging needs to reflect the lived realities of differing contexts. The costs of purchasing sufficient supply of soap and masks is often an expense that the poorest cannot necessarily afford or rationalize and this is not feasible longer term, unless there are subsidies and provision of basic necessities for the most vulnerable.
In terms of research, we need to have longitudinal social science research, with a community centered approach, to understand the impact of the virus on peoples’ lives, their current fears, concerns, practices and behavior. When it’s a clinician lead approach, it is very disease oriented. The messages people are getting is a mixture of messages from the internet, social media, television, and other community members. It is important to understand the lived experiences in order to have appropriate messaging as well as interventions. Fears around quarantine, stigma, the lack of trust on media and news and an already weakened health system further reduces chances of reporting and uptake of services.
Health is a culmination of personal, emotional, mental, physical, social and economic factors. Many of the poor grapple with all kinds of diseases and illnesses all the time. The middle and upper class on the other hand have not faced this level of uncertainty. Unfortunately, vulnerable communities are more familiar with diseases and death and dying. Their lives are about basic survival. The pandemic just magnified the existing inequalities and inequities that have always existed, and a purely clinical approach will not work. We need to address their needs comprehensively. The approach to dealing with such crises in our country is for diverse stakeholders to come together and the government can reach out – NGOs, private sector and other actors. Even if there is a vaccine in the future which is made available for all, for the most vulnerable groups there will continue to be job and food insecurities; then what exactly have we achieved?
What kind of policy, plans and strategies can the Bangladesh government devise regarding the import, production and distribution of vaccines? How can cooperation among the national commission and the current task force be strengthened to ensure efficient implementation of the vaccine access and distribution process?
If we go into partnership regarding vaccines, we should also prioritize our own capacity building. Other issues to consider are quality, prices, availability and accessibility for all. In the longer run, we need to develop our own technological capacities because this pandemic will not be the last one and we need to be prepared.
What kinds of changes and or approaches are necessary to improve the health sector?
Our health system, in general, is not particularly strong, and it has taken a further battering as a result of Covid-19. We also need to ensure that other health services are not completely disregarded, due to the focus on Covid-19. We have a mix of public, private and NGO health providers in the country. There also exists a large informal sector of providers that the general communities/populations rely upon. Strong partnerships and referrals are important and innovative solutions are required to address the workforce shortage within our context. However, the point is not necessarily about fixing the health sector, but about meeting basic needs of the most vulnerable. For example, in slums, access to clean water is not always a reality, and housing is congested and the environment is polluted. Communal latrines and kitchens with poor sanitation and overflowing sewage and garbage is a common sight during monsoon. So how does one achieve a healthy body and a healthy mind if there is a lack of basic infrastructural support? Medicines, vaccines are not the magic bullet. We need to go back to the basics and ensure citizens’ rights are available. We need a socially just model that addresses comprehensively the needs of vulnerable populations and only then can we address health and well-being and the SDGs.
A recent survey revealed, only five percent of the Upazila Health and Family Planning Officers (UH&FPOs) hold a degree in public health. What can be done to improve the skill and competency level of public health officials in Bangladesh?
If this is what the survey reveals, then more training is required. This is a critical discussion we need to have, because post-pandemic we have to strengthen our health system. As we move forward, it is important to reflect on the lessons learned, what worked if at all, and the failures from our Covid-19 approaches, and how we can work more efficiently across sectors and have better planning for the future. Budget allocation needs to be increased substantially. It would be beneficial to have critical review of some of the challenges faced, from quality of PPE and its distribution, lack of sufficient equipment, shortage of bed/ICUs in hospitals, absence of contextualized communication messaging, etc. This will allow us to understand what needs to be strengthened moving forward. The national task force set up was mainly clinician led. Public health is helpful for communities, but health is not just about disease. We need to bring in multidisciplinary voices and opinions, from different stakeholders and actors. There needs to be an open approach because the government cannot do it alone.
Stimulus packages have been initiated and rolled out. The other issue is about understanding why some communities have been more affected than other communities and in what ways. What are some of the needs and priorities? Some of the communities are so impoverished that they cannot follow prescribed guidelines, and many increasingly do not believe in the dangers of the pandemic anymore and therefore for example a reluctance to wear masks in public spaces. Our messaging wasn’t always community-context messaging. As I said earlier, it is important for more social science research to capture and understand the realities on the ground related to Covid-19.
In the public health sector there is little to no resources for mental health care especially in the rural areas, and there is a lack of awareness and taboo surrounding the topic. How can the public health sector start catering to mental health?
In Bangladesh there is little to no conversation around mental health. It’s stigmatized. We are conducting a research with 72 university students and all of them shared experiencing anxiety and depression. Students shared concerns about being able to keep up with about online education and worried about whether they will graduate, get a job, earn money. The uncertainty is daunting. Our urban research in slums found that poor slum women were suffering from sleeplessness, loss of appetite and spoke of heart palpitations. They were extremely worried about the lockdown and about their income and how they were going to pay rent and purchase food.
However, in our country one cannot discuss mental health openly. The everyday stress and anxieties which has been aggravated by Covid-19 needs to be shared. Mental and emotional wellbeing is very important and we need to talk about it. We need to talk beyond clinical diagnosis. Generally normalizing emotional and mental wellbeing is to bring this up in conversations in schools, universities and in the workplace. Unfortunately, mental health is equated with ‘madness’ and the labels and language used to discuss it are derogatory in nature.
Another challenge is that we don’t have enough counsellors or support systems in the country to address this. There is a shortage of clinical psychiatrists and psychologists. There is shame surrounding mental wellbeing, and families object to members accessing any form of counselling or clinical psychiatric care. I think people would be happier and healthier if they could share what they are experiencing and often just being able to talk and share and get good counsel makes a huge difference to one’s quality of life and state of emotional and mental well-being.