Balancing lives and livelihoods: How can South Asia prepare for the next pandemic?
In low and middle-income countries like Bangladesh, strict social distancing measures, such as nationwide lockdowns, in response to pandemics are unsustainable in the long-term due to their knock-on socioeconomic effects
When Covid-19 was first detected in early March 2020, Bangladesh, like the rest of the world, implemented a nationwide lockdown to tame the spread of the virus.
Although Bangladesh was very prompt in taking action to thwart the growth of the infection by shutting down its economy and educational institutions, it took such initiatives when the total number of cases was lower than 50 nationally, and the country only had single-digit Covid-19 deaths.
Such drastic public health measures, however, are not without their economic costs. This is especially acute for developing economies, such as Bangladesh, due to its limited fiscal capacity, over-reliance on ready-made garments and manpower exports, and inadequate social safety net.
Due to such concerns emanating from economic and social costs, Bangladesh started to slowly ease restrictions from early 2021 and onwards, as demonstrated by a gradual decline in the government stringency index (Figure 1). In low and middle-income countries, strict social distancing measures, such as nationwide lockdowns, in response to pandemics, are therefore unsustainable in the long-term due to their knock-on socioeconomic effects.
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Moreover, achieving satisfactory compliance in developing economies such as Bangladesh with mobility restrictions or social distancing is pragmatically challenging, due to the high reliance on the informal sector.
Balancing lives and livelihoods
This raises a very important policy question: In the event of future pandemics, what can low and middle-income countries like Bangladesh do to increase their preparedness, and minimise the costs to the economy and society, while at the same time protecting public health?
This question has been studied recently by a group of academics from the US and UK using daily data on Covid-19 cases and deaths in Bangladesh, India, and Pakistan from 2020-2022.
The study aims to inform public health experts and policymakers in the implementation of restrictions and allocation of resources in a more objective and targeted approach, hence, helping to achieve a fair balance between saving lives and protecting livelihoods.
The study constructs a simple, easily reproducible sub-national contagion risk index grounded on disease spreadability vectors, and empirically validates it. The index essentially captures districts' riskiness in terms of the spread of infections and the ability to minimise the negative public health effects.
The intuition is that the implementation of blanket restrictions can create a huge economic and social toll. If, however, risk areas or virus hotspots can be identified in advance, policymakers can allocate resources to such areas with some potential mitigation strategies, for example, protecting the vulnerable, wearing masks, early vaccination, providing food and relief items, etc. while keeping the economy and educational institutions largely open in low-risk areas.
To develop the index, the authors have used four major domains — urbanisation, informality, migration, and health infrastructure of a district. They have found that the index developed using these domains is highly correlated and explains the variation in Covid-19 cases and deaths in the districts of Bangladesh, India and Pakistan.
To assess the validity of the contagion risk index, the study implements tools of machine learning to examine if the proposed index can accurately predict or identify high-risk zones from medium-risk and low-risk zones.
Using various tests and specifications, the proposed contagion risk index produces appreciable levels of predictive accuracy, where it can accurately distinguish high-risk areas (red zones) from medium (yellow zones) and low-risk (green zoned) areas, on average, more than 85% of the time.
Apart from Bangladesh, the contagion risk index has also been tested and validated against daily Covid-19 cases and deaths data from India and Sindh province in Pakistan. This provides a form of external validation for the proposed contagion risk index.
Figure 2 superimposes the different coloured risk zones and Covid-19 cases for Bangladesh and indicates that the index is robustly identifying vulnerable areas in terms of Covid-19 spread. Such information can be used by public health planners and policymakers in Bangladesh to effectively prioritise areas for risk-mitigation strategies and resource allocation, for example, the allocation of vaccines, hospital beds, ICU and treatment facilities, oxygen cylinders, etc. for better preparedness and responses to the threat of future variants and pandemics.
How do we move forward?
Given the impact of ongoing climate change and another potential pandemic on the horizon, the proposed risk index provides an effective, simple and readily available data-driven approach to identify viral hotspots. This is particularly relevant for low and middle-income countries that are limited by the inadequate availability of high-quality epidemiological data to inform decision-making.
The index can be further improved by adding more relevant and real-time data capturing riskiness and adapting to smaller geographic units, for example, at the ward/union level instead of the district level.
Bangladesh is exposed to various communicable respiratory infections during every winter, and not necessarily those arising from global pandemics. Influenza, parainfluenza, rhinovirus, and respiratory syncytial virus infections, and several bacteria-caused and fungal diseases markedly rise in Bangladesh during the winter period, making hospitals overcrowded.
The simple contagion risk index can be further adapted to consider wintry pressures to identify high-risk viral hotspots for the optimal allocation of health resources if there is an expected level of variation across districts.
However, the implementation of policy measures based on the risk index alone is unlikely to be a solution without adequate preparedness. Preparedness for future pandemics starts at the country level and comprises many different elements. Sound preparedness necessitates strong and resilient health systems, in particular, primary care, to facilitate the detection of disease outbreaks, provide essential care, and support deployment of medical countermeasures.
Many low and middle-income countries, including Bangladesh, have long-standing weaknesses in such areas.
Other measures to improve future preparedness include recruiting, training and prioritising health workers, establishing effective surveillance and response systems to regularly monitor disease outbreaks, including, zoonotic diseases such as the Nipah virus, and building confidence in health services through community health programmes.
Abu S Shonchoy is an Associate Professor of Economics at Florida International University. Moogdho M Mahzab is a postdoctoral scholar at the Woods Institute for the Environment, Stanford University. Towhid I Mahmood is a research assistant at Free Market Institute, Texas Tech University. Manhal Ali is a lecturer in Human Resource Management at University of Leeds.
