by Ajmal Sobhan 17 June 2020
When Minhaz Khan passed away three weeks back in Dhaka, he had been terminally ill for a few years.
With advanced Parkinson’s disease, he had been living under the care of a live-in nurse in his own home. He was dependent on the nurse for feeding, bodily functions, and change of clothes, etc. The night before his death, he became restless, his breathing became labored, and he sounded congested. The family had already decided that he was not going to the hospital, did not want any ventilator, and would be allowed to die as peacefully as possible. When he died at 4 a.m., there were five people in the house – his wife, brother-in-law, the nurse, and a maid. For the ritual of his burial, they needed two Moulvis( Muslim clergy): one for the body to be washed and the other to recite the Koran. There was none available. With the pandemic in full swing, anybody who died was considered a “COVID” death. After many hours they were finally able to locate the two people. Under normal circumstances, the charge for performing the rituals would have been at best 1000 taka each.
However, in the present abnormal time of the pandemic, the two Moulvis agreed to come only with a payment of 10,000 takas per person. After almost 8 hours, the cemetery was ready for Khan’s burial. Only five people accompanied the corpse: the two members of the family, the nurse, the darwan (security guard), and the driver. No extended family or friends came for the last rites. Even though the death of this person had been long anticipated, before the COVID outbreak, no one said anything about Minhaz Khan being COVID-positive. The cemetery attendant was pleasantly surprised to see even five people. He said the last three burials he did, the body was just sent with the driver of the car, with instructions to do the needful.
A patient on ventilatory support was removed from the ICU of a private hospital when it was found that he was COVID-positive. The patient passed away soon after.
During this pandemic, another patient (non-COVID) who required dialysis three times a week was told to come in only two times a week. He too succumbed to his illness as he became nephrotoxic.
Similarly, a young female nurse who checked in critically ill with a non-COVID admission to the hospital was denied admission to the ICU as they did not have a ‘COVID negative’ test to ascertain that she indeed was COVID negative. She expired soon after.
Recently Dr. Tarek Alam (a Bangladeshi physician) has claimed successfully treating Covid19 patients with a combination of Ivermectin – an antiparasitic drug and Doxycycline – an antibiotic. When asked whether these patients were critically ill or had mild symptoms, he said most had mild symptoms, a few were critically ill, but none were on the ventilator. News media ran with the story. Quite soon, both these drugs more or less disappeared from the shelves of pharmacies all over Dhaka. There was tremendous price-gouging in the process, each drug selling at 1,000% percent more than the regular price. People were manically buying these two drugs, not just treating Covid19 patients, but also as prophylaxis for asymptomatic ones. On being asked when they would start using the drugs they had already bought, they would deadpan, “As soon as the first symptoms start.” This whole concept of treating a virus with anti-parasitic and antibiotics goes against the grain of logic and science. There is absolutely no scientific basis for this line of treatment. A randomized trial for such a combination has just not been done. It will assuredly fail the normal protocol that is assiduously followed in the research and development of new antiviral drugs for treating the novel coronavirus. It has allowed the sale of unproven medicine among a population in mass hysteria, as there is no official mechanism for disseminating truthful and verifiable health information to them.
The panic in Dhaka is so pervasive that most, if not all, are yet to step out of their houses in several months. And there is a good reason for the panic – should anyone develop some serious manifestations of the disease, the possibility of finding a hospital and a team of physicians ready, able and willing to treat such patients is scarce at best. People with financial means and some degree of sophistication, have bought themselves pulse oximeters, and some even have bought oxygen cylinders, so that they do not have to go to any hospital. They are deathly afraid to try their luck in one of the Government institutions designated for COVID treatment. The fear-mongering has also started a black market for acquiring a COVID Negative Test report, obviously for a price. It is also becoming apparent that the incidence of COVID in densely populated urban areas is far more than in the villages remotely situated. Even though the Govt. has forbidden private hospitals from refusing acceptance of possible COVID cases, these hospitals are blatantly non-compliant.
And yet the incidence of Covid19 in India, Pakistan, and Bangladesh remains far lower than in the West. With a population of 1.7 billion people in the Subcontinent, the latest numbers are 350,000 cases, with 9,000 deaths. Sri Lanka, with a population of 21.6 million, till June 5th had less than 2,000 confirmed cases and 11 deaths. This may be because of Sri Lanka’s rigid quarantine system and a very early awareness of the need for social distancing. In addition, they also appear to have a more compliant population. Even though the counts in South Asia are yet to peak, on extrapolations based on scientific models, the highest that South Asia would ever reach just before the end of the year, would be 5 million cases with 150, 000 – 200, 000 deaths.
Is there a scientific reason for the low number of COVID 19 patients in South Asia, namely ~ 2%, despite accounting for about 25% of the world population? Probably not, or not yet. But there is plenty to conjecture about. The current median age of the Bangladesh population is 25.7 years, while that of India and Pakistan is 26.8 years (as per 2015 statistics), and that of Sri Lanka, it is 32 years. In essence, these countries have a substantial younger population. The lockdown in Bangladesh was extremely strict with police involvement at every step of its enforcement as long as it was enforced. Though manufacturing sectors have now been allowed to open, new rigid lockdowns are being instituted on the heels of the old ones – those with more than 65 COVID positive cases recorded per 100,000 population, are going back to a stricter lockdown. Under this formula, many areas of Dhaka city are falling into more severe police- enforced lockdowns. The apparent observation that viral infections tend to proliferate in colder climatic conditions, more so than in the heat and humidity of the summer, has received some traction but not entirely. It yet remains a conjecture. There is another reason, which is my own. In addition to having a youthful population, the average man on the street in the Subcontinent is bombarded year-round with bacteria, viruses, and parasites. Endemic diseases such as Dengue, Chikungunya, Hepatitis (A, B, and C), in addition to amebic and bacillary dysenteries, have never left the region. The population as an organic body has learned to live with these and has also gained a degree of immunity to them that their western counterparts never get a chance to, as the latter is just never exposed to them.
There are many other factors involved that have created a sense of total uncertainty in Bangladesh – it is primarily related to the fact that the health care system in the country is least equipped to handle a pandemic such as this. That the private hospital system – an integral part of the health care in major cities – has failed miserably to respond to the pandemic crisis is plain for anyone to see. No significant effort has been made by these private hospitals to triage clinically symptomatic patients who could be considered COVID positive. This has more to do with the bottom line considerations for the private hospitals’ system – it feels that their hospitals might get inundated with suspected patients with the least financial wherewithal to take care of their regular hospital bills, let alone pay for their care in the ICU with a ventilator, should that ever be necessary.
In conclusion, at times, one has to aim for some clarity, confusing medical information forthcoming regularly, and the plethora of statistics continually being bandied about the affected demographics. For starters, a clear distinction can be made between ‘dying of COVID’ and ‘dying with COVID’. For example, an eighty-year-old person with multiple comorbid conditions, and who is COVID positive, may be said to have ‘died with COVID’ rather than ‘died of COVID’. Strictly speaking, this person would die of natural causes, his/her death in all likelihood, being imminent sooner than later. Eighty percent of patients dying of COVID are in the age bracket of 60 years and above. The highest fatality is in the age group of above 80 years. This goes back to the point I made earlier that the Subcontinent is much less likely to see the high number of deaths, as was the case in Europe and the USA. Besides, while all of the medical attention is being currently concentrated in treating COVID patients in a hospital environment, it is likely that an average patient suffering from either hypertension, or diabetes, or kidney ailment, or liver ailment; or a cancer patient needing chemotherapy, will inadvertently be ignored or be set aside for the moment – which will only go toward creating far more morbidity and mortality when the novel coronavirus has eventually tapered off.
An effective Covid19 vaccine is forecast to be approximately 12 months away. Antiviral meds are already in use, and new and more effective ones are expected to be available soon to reduce the intensity of the disease and expedite an early recovery. Notwithstanding these, the new virus is here to stay with the global community with all of the intercontinental connections that it entails. It cannot be avoided as quarantine and lockdown measures will not be tenable for long. The inevitable exposure to this novel coronavirus over time, just like the influenza virus, we are seasonally exposed to each year, will eventually create a critical mass of the population that will develop immunity. When that critical mass gets to be around 60-70 %, a “herd immunity” will have been achieved. Realistically speaking, more people will test positive in the ensuing months for the virus. Also, more among the vulnerable population (older, and or with multiple comorbid conditions) will, unfortunately, succumb to the disease.
The enormous breadth of personal freedoms we enjoy as citizens living in liberal democracies of the West may be turned around to reinforce within us an abiding sense of personal responsibility, one that is geared toward caring for each other. In most Asian countries, even though they are ‘democracies”, the government wields enormous power over the populous and can institute immediate and rigid edicts with impunity. In this regard, our solemn duty toward social distancing, unflinchingly wearing face masks in the public places, and practicing strict hygiene – both personal and societal – will be paramount. That is the daunting reality confronting us. The sooner we vow to embrace this reality, the better will we be equipped in matters of reduction of our stress and anxiety levels – both personal and societal; and thence, march as one global community on the path of general wellbeing, human welfare, collective good, and world peace.