How Bangladesh handled SARS CoV-2: Interim evaluation through a scientist's lens

As of 2021, the Sars-CoV-2 virus has reportedly killed more than 5.4 million people worldwide and there are no signs of stopping this deadly virus yet. To date, the world has experienced several variants and the Omicron variant is the latest addition. 

In the case of the Omicron variant, we are getting new information almost on a daily basis. Now it has become established that this variant is highly effective in transmitting the disease and also in reducing the effectiveness of the vaccine. 

People also wonder what if Delta and Omicron are combined to become as deadly as Delta and transmissible as Omicron, which may be named Del-omicron, then what will happen to us? 

This warrants other questions: how much progress has Bangladesh made in the last two years in dealing with this virus? Has Bangladesh been able to manage the pandemic at all? 

There is no simple answer as the virus seems to be always one step ahead of us. 

Recently a Canadian immunologist described the virus in a simple way, saying that "The virus is like a boxer who lost in the first round, managed to get up again, shrug off his head and attack the opponent with more power in the second round and in a new way". Some people say that this virus will never leave and stay with us as we are living with the seasonal flu virus. So, we have to continue fighting this virus. 

We have been seeing and dealing with one or more microbes and epidemics every year for the last two decades, but recently it has increased. Nipah virus, West Nile virus, Chikungunya virus, SARS, MERS and many more, to give a few examples. 

Working in a Canadian public health laboratory, we often have to do a SWOT analysis in the middle and at the end of any outbreaks, which is kind of a routine procedure. SWOT's abbreviation is Strength, Weakness, Opportunity and Threat, and it is a tool people use to evaluate any work. 

In other words, SWOT analysis is a simple tool or method that can help anyone to analyse any task and create a successful strategy for similar future events. The recommendations that come out from the SWOT analysis are usually followed to combat future outbreaks or epidemics with the hope that there will be no chance of repeating the previous mistakes. 

Now, if we consider evaluating how Bangladesh dealt with Covid-19 as a task, we must see what was done right, what went wrong, what opportunity we missed, what kind of future dangers may come and what can be done to save us from future dangers using SWOT analysis findings. 

There is not much to say when it comes to Strength. However, Bangladeshi people are very resilient and if that resilience would have been used appropriately, it would have been great. Bangladesh has several very well-run private laboratories but that strength was not fully utilised when it came to diagnosing patients. Whereas in developed countries, both public and private laboratories worked together. 

Bangladesh had another strength- manpower. We had a strong scientific workforce but unfortunately, that strength also had very limited use.

Bangladesh could deal with the pandemic more efficiently compared to many other countries, as we had more than two months' time before it came to our country. Bangladesh detected its first Covid-19 case in the middle of March 2020, two and half months after the virus was detected in Wuhan. It's a lot of time that could have been utilised to make a full proof plan. 

We could have developed protocols for hospitals to deal with Covid patients and set up laboratories to do proper testing, train nurses, technologists, and allied health workers on how to handle patients and their samples in a proper manner, up to Upazilla levels. 

Another great opportunity that we missed is that we couldn't upgrade the schools, college and university building infrastructures, while educational institutes were closed during the lockdown. Most of the private schools, college and university are being operated in residential buildings and have no proper ventilation, which is extremely important not only for dealing with the SARS CoV-2 pandemic and other infectious disease outbreaks, but also for general health. 

Following the WHO announcement, Prime Minister Sheikh Hasina immediately called upon all citizens and residents to abide by the basic rules of public health and i.e. wearing masks, washing hands and keeping physical distance, and this is highly commendable. Maybe the PM's messages were not relayed to the people in a way that they would have accepted.

Healthcare had ample opportunities to do that research and find out efficient ways of delivering messages so that people would adhere to them more than what we have seen. 

What can we learn from this? I think now is the right time to make society aware of public health. The government has now decided to teach all subjects to all students up to 10th class. This is definitely a good initiative. Let's just hope that the students will be taught about population and public health. Especially science lessons should be given from the second grade onwards, so that children can learn about health education and simple topics such as avoiding public gatherings, wearing masks in public, maintaining physical distance, washing hands and using hand sanitisers if necessary.

Bangladesh needs to take steps to establish a modern vaccine industry of international standard.

Bangladesh also couldn't do research on multiple areas of SARS CoV-2 or Covid-19. Despite the ability to monitor the disease, no measures were taken in the early stages of the Covid-19 outbreak, which is a very important step to make policy decisions for any public health outbreaks, epidemics or pandemics like this. 

While discussing the weakness, a little introduction is needed. For those of us who are involved in laboratory diagnosis, we are proud to say that the role of the laboratory for diagnosing and caring for a patient is 75% and the role of a physician is only 25% for patient management. In most cases, doctors all over the world treat their patients based on the results of the laboratory's test results. 

When Covid-19 was detected in Bangladesh, the first problem that we faced was to diagnose the disease quickly and characterise the virus. It was a major problem because of the lack of proper utilisation of public and private laboratories, the lack of reagents, chemicals and test kits etc. 

And another severe weakness was the shortage of qualified and skilled workers and scientists in the major hospitals and public health institutes. Although we had a lot of microbiologists in Bangladesh, there was no system in place to utilise them. 

The ratio of doctors, nurses and laboratory technologists in the medical system in Bangladesh is 1: 5: 3 and this ratio was established immediately after the independence of Bangladesh when our population was only 75 million. 

In 2021, we celebrated the 50th golden jubilee of our independence. The irony is that the ratio of doctors to nurses and laboratory technologists is still the same. The most surprising fact is that scientists have no place in the health sector, especially in academic hospitals. The role of scientists in health sciences is infinite, especially in the field of laboratory diagnosis, test development and test implementation in laboratories anywhere in the developed world. 

Doctors in every major hospital in the developed world are working closely with laboratory scientists such as microbiologists, biochemists, geneticists, molecular biologists parallelly and providing the best care possible. 

If the Ministry of Health of Bangladesh would review the laboratory organograms of the developed countries from time to time and appoint microbiologists, biochemists, geneticists, molecular biologists in academic hospitals, then we would have been better off from the beginning. We could diagnose and manage Covid-19, as well as patients with other deadly infectious diseases. 

Giving opportunities to scientists to work in the health sector will also trigger and encourage research work which is largely missing in any academic hospital. 

It's been two years since the Covid-19 pandemic emerged, but sadly, the diagnosis of the virus is still far from satisfactory in Bangladesh. Many district-level hospitals still have to send samples to bigger cities for testing. 

I think the health department can take a decision on an urgent basis and develop current standard biomedical laboratories, at least in all the district hospitals, so that in future the district level hospitals no longer have to send the samples to other big cities. 

There are all kinds of experts in Bangladesh but unfortunately, they don't often work together. Public and private sector doctors, scientists, teachers, businessmen, administrators all need to create an environment to work together with a unified goal.

It would be helpful to discuss Opportunity and Threat together. To my knowledge, worldwide, more than 200 organisations have worked and are still working to develop a vaccine for the SARS CoV-2 virus. Millions of physicians around the world are trying to combine different drugs to treat this disease, and hundreds of companies are trying to find new drugs to cure the disease. In my 35 years of professional life, I have never seen such an extraordinary effort to fight a virus from all corners of the world. 

Unfortunately, I have to say that no initiative has been taken by the Bangladesh govt regarding diagnostic kits or medicine or vaccine development. The good news though, recently a few companies started producing generic drugs against SARS CoV-2. 

My question is if Bangladesh can be a world champion in the pharmaceutical, garments, agriculture industry etc., then why can't it be a champion in developing laboratory diagnostic kits and the vaccine industry?

In the diagnostic arena, the most expensive Rapid RT PCR kit has been purchased and is still being purchased because of the lack of proper laboratory facilities. If the country's microbiologists, biochemists and nutritionists were used properly, they could easily develop laboratory tests themselves. It would provide much better laboratory test services at a very low cost and this service could be even provided in different district hospitals. 

I think it is extremely important 1. to produce more up-to-date and advanced laboratory technologists to deal with the ongoing epidemics and future epidemics or epidemics for a population of 16-17 crore; 2, giving priority to industrial development related to Laboratory Diagnostic Kits and Materials and; 3. to take steps to establish a modern vaccine industry of international standard. 

The demand of the hour is that scientists, the business community and concerned ministries should be enthusiastic about the solution and the government should help these sectors in every possible way to make those happen. 

In addition, an Advanced Infectious Diseases Research Institute and an Advanced Vaccine Research Institute are essential for the service of 16-17 crore people. If necessary, it can be done by collaborating with the best institutes in the developed world. 

As we all know, millions of dollars of foreign currency are currently being earned by the Bangladeshi pharmaceutical and garment industries every year. I believe that if the right steps are taken then the day is not far away when the laboratory and vaccine industries will earn equal or more foreign currency at the same rate, if not more. Apart from earning foreign currency, Bangladesh will be able to meet its own needs in time and won't have to be dependent on others.

In addition to the above, Covid-19 has given us a golden opportunity to develop the Upazila, District and Divisional level hospitals and especially the hospital laboratories with manpower and equipment, and the opportunities have not been lost yet. 

In order to improve the manpower of the laboratory, it is necessary to increase the manpower of laboratory technology education, i.e., modern subjects like molecular technology, genomics, bioinformatics, data mining etc., need to be added to the syllabus and should be taught accordingly. The laboratory must employ qualified physicians as well as scientists such as microbiologists, biochemists, geneticists, molecular biologists. 

At present, laboratory samples are sent to our neighbouring countries for many tests such as for cancer, genetic diseases and many others. First, this is a very time-consuming process and second, it is more costly because of shipment, profit sharing etc., and last but not least, is a waste of foreign currency. If the above issues can be resolved then not only will the quality of service increase in Bangladesh but also will be able to save billions of dollars every year and also earn billions more.

I hope that the Government of Bangladesh; the concerned Ministries, especially the Ministry of Health, Physicians and Health Scientists will take the time to conduct a full Covid-19 SWOT analysis together and provide guidance on how to deal with the ongoing and future outbreaks, epidemics and pandemics. The proposals I mentioned above are not a luxury. These are essential and important for a healthy society. I hope that the concerned authorities will consider my proposals sincerely and seriously.

The Author is an international expert on zoonotic and arthropod-borne diseases. He is also a Clinical Microbiologist and Head, Zoonotic and Emerging Pathogens Laboratory, BC Centre for Disease Control, Vancouver and Clinical Professor, Department of Pathology and Laboratory Medicine, University of British Columbia.