22 years with dengue and a flawed healthcare management system

Rotna was running through the corridors of Shaheed Suhrawardy Medical College Hospital last Wednesday, her husband's, Sajjad's, test reports were tightly clasped in her hands. 

The reports said Sajjad has dengue and his platelet count had dropped to 14,000 (for men, the average count lies between 135,000 and 317,000 per microliter of blood). 

Rotna was desperate to get her husband admitted to the hospital and was looking for an available bed. After an hour, she took Sajjad to a private hospital in the capital's Mohammadpur area.   

"We thought it was a seasonal viral flu, and didn't take it seriously. After a week, when the fever didn't go down and he hadn't urinated for almost 12 hours, I got scared and got him tested. 

The doctors said I have to immediately get him admitted," said Rotna, her voice quivering. 

On the sixth floor of the hospital, there are five dengue units, all overwhelmed with patients. The neurosurgery department's ward has been transformed into a dengue ward. The neuro patients have been shifted to other wards.

Dr Taha, a duty doctor at the dengue unit said, "we are receiving dengue patients every day and it doesn't seem it will stop anytime soon. More than 20% of these patients are in serious condition."

According to him, almost 90% of the dengue patients are from Dhaka, while 10% are coming from other districts.

It has been 22 years since dengue first appeared in Dhaka. It remained, more or less, a metropolitan disease for all these years. However, things appear to have taken a turn. After a lethal pandemic recently retracted its claws of death, we once again face an outbreak, a familiar foe. But this year, dengue is no longer confined to the metropolitan area. It has spread to the suburbs and villages. 

And, the death toll has broken all previous records. 

Photo: Rajib Dhar

Till Friday morning (5 November), the Directorate General of Health Services (DGHS) recorded a total of 167 deaths from dengue in the country, which is higher than the figure from the last two years combined. Nine dengue deaths, the highest in a single day this year, were recorded on Thursday.  

From January 1 to 5 November, DGHS has recorded 42,199 dengue cases and 38,295 recoveries so far this year. Among them, 28,275 people are in Dhaka and 13,924 are outside Dhaka. 

3,737 dengue patients are admitted to various public and private hospitals across the country. Among them, 2,254 are in 53 hospitals in Dhaka. The remaining 1,483 people are under treatment in other departments outside Dhaka.

Physicians and health experts have cited comorbidity (suffering from multiple diseases) and late hospitalisation of dengue patients as the main reason behind the spiked death toll. One factor to note here, many patients are travelling to Dhaka for treatment. 

Again this year, two new variants have emerged–Den 3 and Den 4–which are more lethal than previous variants, and seem to attack and dangerously affect all, including children and women. 

Over-booked hospital wards and patients' relatives in disarray can work as flashbacks, trigger memories even, and fully remind us of the last time when the healthcare system was overwhelmed. Not much time has passed since we met and lived through the Covid-19 pandemic. 

Now, while the reeling effects of Covid in hospitals have been tamed to a large extent after nearly three years, it begs the question: are we not supposed to have a well-organised healthcare management system in place by now? 

Photo: Rajib Dhar

This would include, but is not limited to, ICUs with necessary amenities, well-trained nurses and doctors properly distributed to the upazilas and suburb locations, and adequate diagnostic capacities. 

But what we are seeing is that more patients suffering from dengue are coming to Dhaka for treatment. Does this attest to the fact that we are still not prepared to tackle emergency medical situations? 

Public health expert Prof Dr Be-Nazir Ahmed said, "This means we didn't take any lessons from our previous mistakes. We absolutely have no preparation at the local level." He further added that Gaibandha still has no ICU beds, even after being one of the Covid-19-prone areas. 

Doctors outside the capital were not given proper training in dengue management. The DGHS has provided training to some 2,000 doctors, but all of them are in government hospitals in the capital; they are not among the upazila-level doctors. 

According to the reports published in the media, district and upazila-level doctors don't have the necessary amount of dengue testing kits (NS1 antigen test kits). Introduced in 2006, the kit allows rapid detection on the first day of fever, before antibodies appear some five or more days later. 

Why were they not given proper training or not provided with NS-1 kits? When we contacted several DGHS officials with these questions, they either failed to respond or refused to respond to our questions. 

We reached out to Dr ABM Abdullah, emeritus professor and personal physician of the prime minister, for answers. He said, "You cannot blame any one party here. Both the people and the administration have some faults. Dengue is not something new here in Bangladesh, so we have an idea about how to deal with it. But what happens with the patients is that they think the capital city has better health opportunities; they just cannot trust the local health complexes and hospitals."

According to him, upazila-level doctors are also doing good but still, the patients somehow do not trust them. And then some can afford to travel to Dhaka for treatment and get admitted to private hospitals. I believe this is the main reason for them to come from outside of Dhaka."

Dr Abdullah and Dr Be-Nazir pointed out a couple of other underlying reasons behind this year's death rate. Dr Abdullah said that it depends on the type of fever or the virus. There are four types of dengue–Den 1, 2, 3, 4. The Den 3 and 4 are extremely lethal. The ones infected by Den-3 are at the highest risk. 

Photo: Rajib Dhar

"And the second reason is most of the people who are dying [possibly] had been previously infected by the virus once or twice. And every time an individual is infected by this virus, his/her immunity [system] weakens, hence the third or the fourth time it gets severe for the person," explained Dr Be-Nazir Ahmed.  

Dr Be-Nazir, also a former DGHS director, further added that doctors are yet not trained to address this virus. "We still consider platelet count to be the primary parameter for dengue testing. No one talks about PCB [packed cell volume] or the hematocrit ratio test, which is more effective in determining the virus. This ratio should be under 40, but if it increases, the patient should immediately be hospitalised."

Both also spoke about comorbidity and how it can increase the likelihood of the dengue variant causing more harm to the body, once infected. Comorbidity, in this case, means someone is already suffering from diseases like diabetes, blood pressure, brain stroke etc. 

Is there a way out?

On how to solve this, Dr Be-Nazir said the focus should be given to prevention and also capacity building. "Dengue has a connection with the environment - a specific amount of rainfall and humidity. This year the monsoon has lasted for a long time. It may continue up to December," he explained, adding a clean environment is crucial. 

"Only the entomologists can determine where steps should be taken. Fogging is not enough. Larvicide needs to be used to kill larvae. A general fogger will not understand this science. We need to address this immediately," said Dr Be-Nazir, further adding, "every city corporation, local government and hospital needs to improve its human resource by hiring more entomologists. They need well-equipped labs, necessary chemicals and pesticides and well-trained doctors and nurses. And for all of this, we need a well-planned budget. 

Now it depends on the government whether they would focus on strategic planning or not."