Covid-19 response: Inclusion as the first mantra
Community participation is even more pressing as the virus has already invaded most localities. This is the first of the two part series
The people of Bangladesh are in the midst of one of the greatest challenges this country is likely to face in our lifetimes. The Covid-19 pandemic threatens lives and livelihoods at a time when Bangladesh was celebrating achievements in most socio-economic development sectors, many of which surpassed those of our economically powerful neighbours.
Overcoming this colossal challenge requires education, participation and contribution of every citizen. We have seen how instructions on precautions have been and continue to be ignored. A recent large-scale survey, to be released soon by a private university, has documented the extent of current practices in different districts, which indicates an ominous picture. The widespread lack of the very minimum of steps to avoid an infection – even in so-called red zones – is dismaying.
In the past, we as a nation faced and successfully overcame many disasters – floods, droughts, cyclones, wars and famine. A common success factor was the participation of citizens in the mitigation efforts. This was also true for how we successfully we tackled many serious public health problems which were holding the country back.
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From over six children per woman in the 1970s, the average fertility rate is just over two. Immunisation rates here are comparable to the wealthiest of countries. Oral rehydration therapy was also developed and championed here.
For these and many other health interventions, the government, sometimes in collaboration with non-governmental organisations, successfully mobilised the entire country, and was specifically inclusive of women, menfolk, local government, mosques, temples, schools, village practitioners and the medical community, as well as the civil society, NGOs, media, celebrities, students and teachers. In short, people from all walks of life were included, with a strong emphasis on rural communities. While these are all significant achievements, the interventions we need for Covid-19 are far more complex.
Unfortunately, we are missing an approach that makes us join hands in tackling the current crisis. We lack and sorely need a coordinated response at national and local levels.
The government's National Preparedness Response Plan for Covid-19 (dated March 2020) indicates the formation of different national- and local-level committees, which is good news. However, these committees, while not the only means for coordination, seem to have missed the critical element of including people from the many sectors essential to the response – including, for instance, the non-governmental organisations and the private sector.
Economists and social scientists are also missing from the technical committee – their expertise is surely vital. The current thinking seems to view Covid-19 as a medical problem. Certainly, two of the most important national committees (National Coordination Committee and National Technical Committee) are both headed by the Directorate General of Health Services. Unfortunately, the challenges we face go well beyond health.
Just a cursory look at what others are doing shows the importance of not only bringing in a wide array of skills, but also ensuring guidance that is fact-based and transparent. Rwanda, which has mounted an exemplary response, immediately constituted a national steering and technical committee made up of all government agencies, as well as the private sector representatives from all sectors. Their rationale stemmed from acknowledging the need for diversity to provide insights into the affected sectors and to improve the relevance of interventions.
Many countries have taken a similar whole-of-government approach and widened the network beyond traditional advisers. Interestingly, the UK's Scientific Advisory Group for Emergencies (SAGE) started with membership from a broad array of experts representing almost all conceivable interest groups, headed by the country's Chief Scientific Adviser. And yet, with time, an additional independent SAGE was formed with people exclusively from outside the government.
In other words, while careful attention to relevant insights and stakeholder involvement is needed, it is not enough. Independence is also emerging as a vital component of leadership in these times. As with other countries, we will learn as this complex crisis develops. We should, however, not lose time to position ourselves to do the best we can do. We can and will, we hope, do and think better.
Despite the current difficulties, people from different sectors and walks of life are not sitting idle. We are aware of several initiatives started by people taking charge of the situation themselves and as best they can – occasionally with the government, too. A Corona Resilient Village Programme, spearheaded by the Hunger Project, is making people aware of the disease and the need to religiously follow the health etiquettes, in 1,500 villages.
Brac, through its extensive network and in collaboration with the health ministry and others, is organising community support teams in different villages to raise awareness and identify suspected cases for referrals and support. A further example with signs of progress is a partnership forged between the civil surgeons and other administrative wings of the government, local members of the civil society, and non-resident Bangladeshis.
Pulled together by the Sylhet-based Kidney Foundation, two large isolation centres are being set up amid a surge of Covid-19 and Covid-19-like infections which have already overwhelmed the existing local capacities. The government lent its two new yet-to-be commissioned upazila health complex buildings in Khadimpara and South Surma, and local volunteers along with non-resident Sylhet residents provided most of the financing and human resource support.
Community participation is even more pressing as the virus has already invaded most localities. We have a long way to go and urgently need to establish community-based responses in terms of prevention, case detection/contact tracing, and provisions for home-based care and isolating cases. From whatever evidence we have seen, people are ready to take on the challenge to defeat the virus, but they need to be rallied and supported as it happened in 1971.
This far, Vietnam remains a success story in the fight against Covid-19, with no reported deaths. There, the government ensured that the public was on board for their sweeping and aggressive strategy to work. According to a senior official, "We have to mobilise all of society to the best of our capability to fight the outbreak together".
Active participation of community is also said to be a major factor in containing the disease in India's Kerala state. Kerala, like Bangladesh, had a significant number of non-resident Keralites who returned home after the crisis began. They were allocated specific care centres to wait out a period of quarantine. Supervised by the village panchayat, community health workers provided awareness, identified symptomatic cases and strictly enforced the initial lockdown.
We have much to learn from the Kerala example. In Bangladesh, overseen by the union parishads and implemented by NGOs, broad-based village-level Covid-19 prevention committees can take the lead in prevention and initial management of suspected cases. Such committees can also be entrusted with the task of distributing food to vulnerable families. The Corona Resilient Village programme, as mentioned above, has already shown that these types of measures are entirely possible and feasible.
With the government's backing, inclusive and locally-led committees can help commandeer resources, influence behaviour change, and coordinate the needed initiatives within communities. If provided with information, small financing, and planning support, such committees can achieve a great deal – more than what is possible through externally imposed or piece-meal partnerships.
While mistakes will surely be made as this crisis unfolds, the chances of better outcomes and accepting the consequences of actions will surely increase if decision-making is locally-led and engagement is inclusive.
Mushtaque Chowdhury is a professor of population and family health at Columbia University, and convener of Bangladesh Health Watch. Fawzia Rasheed is a former senior policy adviser to the World Health Organisation
