Dengue, public health in Bangladesh: A socially constructed perspective
Dengue, a mosquito-borne viral infection, is a significant public health concern in Bangladesh and around the globe. The World Health Organization (WHO) estimates that dengue affects approximately 390 million people annually in over 100 countries, resulting in about 25,000 fatalities and costing billions of dollars in health care and lost productivity.
Dengue is caused by one of four serotypes of the dengue virus that are closely related (DENV-1, DENV-2, DENV-3, and DENV-4), which can produce symptoms ranging from mild fever to severe hemorrhagic fever and shock. Infected individuals can develop immunity to one serotype but not the others; subsequent infections with a different serotype can increase the risk of severe dengue. With its tropical climate and concentrated population, Bangladesh is especially susceptible to regular dengue outbreaks, particularly in urban and semi-urban areas. The dynamism and complexity of dengue necessitate a comprehensive response that addresses both its biological and social dimensions.
Bangladesh experienced its second-largest dengue outbreak since 2000 in 2022, with over 52,000 confirmed cases and 230 fatalities reported by the Ministry of Health and Family Welfare (MOHFW) as of November 2022. This epidemic, which began in June, affected all eight divisions of the nation, with Dhaka being the most brutal hit. The scale and seasonality of the outbreak were atypical, coinciding with an unusually high quantity of precipitation, high temperature, and high humidity, all of which led to an increase in the mosquito population. The situation deteriorated further in 2023, with dengue cases increasing to 4,603 by June and more than 1,000 patients being treated in hospitals nationwide.
Keep updated, follow The Business Standard's Google news channel
The current outbreak in 2023 is unprecedented in scope and seasonality, with 19 deaths reported in a single day on July 19th, setting a record. The attack has added to the already overburdened healthcare system, coping with an intensifying COVID-19 crisis. Due to limited resources, inadequate surveillance, and a lack of public awareness, the health authorities have had difficulty diagnosing, treating, and preventing dengue cases. The Ministry of Health and Family Welfare (MOHFW) has taken numerous measures to control the outbreak, including increasing hospital bed capacity, disseminating insecticide-treated nets and larvicides, conducting mass awareness campaigns, and coordinating with other sectors and stakeholders.
Regarding Dengue-related research, International Centre for Diarrhoeal Disease Research, Bangladesh, assessed the knowledge, attitude, and practice (KAP) of dengue among 6,000 households in six districts of Bangladesh between July and November 2019. Using a structured questionnaire to collect data on various aspects of dengue, such as transmission modes, symptoms, prevention methods, treatment options, information sources, and health-seeking behaviour, the study found that although most people had heard of dengue (98%), they had misconceptions about the breeding habitats (only 37%) and biting times (only 28%) of the Aedes mosquitoes that transmit the disease.
In addition, many individuals failed to recognise the symptoms of dengue (only 54% correctly identified fever with rash) or seek prompt medical care (only 64% visited a qualified doctor within 24 hours), which increased the risk of complications and death. The study also found that education level was an independent predictor of dengue knowledge and awareness (higher education was associated with higher scores) and that television/radio was the most prevalent source of information (86% of respondents). Based on these findings, the study recommends that health authorities develop and implement targeted and effective health education programs to increase the KAP of dengue among the population, particularly the less educated and rural people. Additionally, the study suggested that the media should play a more active role in disseminating accurate and consistent information on dengue prevention and control.
However, beyond these technical aspects, there is also a need to critically examine the social, economic, and environmental factors contributing to the emergence and spread of dengue in Bangladesh. Dengue is not only a biological phenomenon but also a socially constructed one, as it reflects the inequalities, vulnerabilities, and power relations that shape the health outcomes of different groups of people. The impact of the disease extends to various aspects of society, such as health, economy, education, environment, and governance. Some of the factors that influence the transmission and burden of dengue in Bangladesh include:
Rapid urbanisation and population growth create overcrowded and unplanned settlements with poor sanitation, water supply, and waste management systems, providing ideal breeding grounds for mosquitoes.
Climate change and variability, which affect the temperature, rainfall, humidity, and sea level patterns, alter the distribution and abundance of mosquitoes and their habitats.
Poverty and social marginalisation limit access to health care, education, and information for many people, especially women, children, ethnic minorities, and migrants.
Weak health systems and governance hamper the surveillance, diagnosis, treatment, prevention, and control of dengue cases due to inadequate resources, infrastructure, human resources, policies, regulations, and coordination among different sectors and stakeholders.
Addressing these factors requires a multidisciplinary and multi-sectoral approach that goes beyond the biomedical model of health and disease. It requires engaging with the social determinants of health and addressing the root causes of societal vulnerability and inequity. It also requires fostering community participation and empowerment in decision-making processes and interventions related to dengue prevention and control. Moreover, it requires strengthening the health system and governance structures to ensure universal health coverage, quality health services, and effective collaboration among different actors.
Dengue, for example, disproportionately affects poor and marginalised populations who live in overcrowded, unsanitary, and poorly ventilated environments that facilitate mosquito breeding and transmission. These populations also have limited access to health care services, social protection, and education, making them more susceptible to infection and less equipped to deal with its consequences. The outbreak has overwhelmed hospitals and clinics, resulting in longer wait times, a lack of beds and resources, and an increased risk of infection for patients and healthcare professionals. In addition, dengue can result in stigma and discrimination within the affected communities, as they may be blamed for spreading the disease or neglected by their neighbours. The health professionals and volunteers who provide care and support to dengue patients and their families face several obstacles, including a lack of training, equipment, transportation, communication, motivation, and recognition.
Temperature, precipitation, humidity, and vegetation are environmental factors that influence Dengue. These factors influence the reproduction, survival, biting behaviour, and virus transmission of mosquitoes. According to WHO, since June 2022, an unusual amount of precipitation has created favourable conditions for mosquito breeding in urban and semi-urban areas, causing the 2023 outbreak. By expanding the geographical range and seasonality of dengue, climate change may increase the risk of future episodes. The political economy of development, which prioritises economic growth over social justice and environmental sustainability, drives these factors. Dengue can have adverse effects on the natural resources and ecosystems of Bangladesh, including water quality (due to increased use of pesticides and larvicides), biodiversity (due to loss of mosquitoes' natural predators and habitats), and climate change adaptation (due to increased human health vulnerability). Among the interventions that have been implemented or proposed to mitigate these effects are the following: promoting eco-friendly vector control methods (such as biological control agents or botanical insecticides), enhancing environmental management practices (such as improving water supply, sanitation, waste management, and urban planning), and integrating dengue prevention into climate change adaptation strategies (such as early warning systems or community-based resilience).
There are direct and indirect economic costs associated with dengue for individuals, households, and society. These costs include medical expenses (such as diagnosis, treatment, and hospitalisation), income loss (due to absenteeism from work or decreased productivity), education loss (due to absenteeism from school or reduced performance), and public expenditure (on healthcare and vector control). In addition to affecting the tourism industry, trade, and investments, the outbreak can also impact public confidence and social cohesion. The total economic impact of dengue in Bangladesh in 2019 was estimated to be $1.84 billion, according to a study on 20 August 2020, titled "Dengue in a crowded megacity: Lessons learnt from 2019 outbreak in Dhaka, Bangladesh" by Mohammad Sorowar Hossain et al. With increased severity this year, it may appear to rise to higher levels.
Dengue can also disrupt the education system by affecting student and teacher attendance and performance. In addition, the pandemic can force schools to close or reduce their activities to prevent the spread of the disease. In addition, dengue can impact the quality of education by diminishing the availability of learning resources and facilities. In Bangladesh, dengue reduced school attendance by 6% in 2019, according to a study on 10 June 2021 titled "Knowledge, awareness and preventive practices of dengue outbreak in Bangladesh: A countrywide study" by Md. Imam Hossain et al. So far, we have seen that providing free or subsidised health care services and social protection schemes for dengue patients and their families, promoting health insurance and contingency funds to cover medical expenses and income losses, improving the quality and efficiency of health care delivery and vector control interventions, and conducting cost-effectiveness analysis and economic evaluation of various interventions are some of the measures that have been taken or proposed to reduce these impacts.
Prevention and control of dengue require effective governance and coordination among various sectors and stakeholders at local, national, and international levels of the health system. However, the outbreak in 2023 has revealed some gaps and challenges in dengue governance in Bangladesh, including a lack of timely surveillance and reporting, inadequate vector control measures, insufficient public awareness and participation, weak inter-sectoral collaboration, and inadequate resource mobilisation. These obstacles have hindered the ability of health authorities and other actors to respond effectively and mitigate the outbreak's effects on the population. The public's misconceptions and lack of knowledge about dengue necessitate an immediate increase in health promotion campaigns to dispel these misunderstandings.
Such campaigns should educate the public about the symptoms, transmission, prevention, and treatment of dengue, as well as encourage community participation in reducing mosquito breeding sites and seeking prompt medical care if infected. In addition, the surveillance, vector control, and clinical management capacities of the health system must be strengthened to combat future outbreaks. This includes improving the quality and timeliness of data collection and analysis, enhancing laboratory diagnosis and case confirmation, expanding the use of practical vector control tools such as insecticide-treated nets and larvicides, training and equipping health workers to provide appropriate case management and referral services and ensuring adequate supplies of medicines and blood products for severe cases. These interventions should be governed by evidence-based policies and guidelines that are updated frequently and disseminated to all relevant stakeholders.
Adopting a human rights-based approach that recognises dengue as a matter of social justice and guarantees the participation, empowerment, and accountability of all stakeholders is, therefore, essential for effectively addressing dengue. This approach should respect the dignity and rights of all dengue-affected individuals, particularly those marginalised or discriminated against because of their gender, age, ethnicity, religion, disability, or socioeconomic status. In addition, adopting a human rights-based approach necessitates promoting inter-sectoral collaboration that integrates health with other sectors, such as education, water, sanitation, housing, urban planning, and environmental management. This collaboration can assist in addressing the underlying causes of dengue by enhancing the living conditions and quality of life of at-risk populations. Improving access to education, for instance, can increase literacy and awareness regarding dengue prevention; improving access to water and sanitation can reduce mosquito breeding sites; improving housing quality can protect against mosquito bites; improving urban planning can reduce overcrowding and unplanned settlements; and improving environmental management can reduce deforestation and land degradation that affect mosquito ecology. Adopting a human rights-based approach fosters global solidarity and cooperation that assists low- and middle-income countries such as Bangladesh to gain access to the resources, technologies, and innovations necessary to prevent and control dengue. This includes providing financial support for strengthening health systems; sharing technical expertise and best practices for surveillance, vector control, and clinical management; facilitating technology transfer and capacity building for developing new tools such as vaccines, diagnostics, and therapeutics; supporting research and development for the generation of new knowledge and evidence; and advocating for political commitment and policy coherence at regional and global levels.
By doing so, we can not only reduce the burden of dengue but also improve the health and well-being of all people in Bangladesh.
Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the opinions and views of The Business Standard
