IEDCR: Why and how it failed us
The ‘fire brigade of our healthcare system’ lacks the manpower and resources to live up to its mandate. So what is being done now?
Eighteen months and 22 days ago, many did not know of the Institute of Epidemiology, Disease Control and Research (IEDCR) in Bangladesh, at least not of its entirety. This could be construed, perhaps, as a good thing. But the coronavirus pandemic changed that.
When the virus travelled across borders from Wuhan, China, infecting and upending lives, in the early days of last year, it crippled not only the healthcare sector, but also healthcare intelligence hubs even of developed countries. It took the world by surprise.
Surprise might not be the accurate word here. Because healthcare industries and governments across the world knew of a highly communicable 'new' virus, detected in Wuhan, by 29 December, 2019 latest. By February, it can be deduced that all top officials were made aware of the virus' full potential to become a pandemic.
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This is where surveillance, research and disease control institutions, across the world, come in the spotlight. Because they are tasked with the responsibility of just that: to know or predict the scale of communicable viruses and prepare accordingly. For Bangladesh, that institute is the IEDCR.
"They [IEDCR] saw the coronavirus pandemic on a small scale," said Dr. Be-Nazir Ahmed. He believes that the institute approached what was already understood as a global pandemic before March 2020, through a conservative lens.
Dr. Ben-Nazir Ahmed worked in the IEDCR for seven years, starting from 2004. He worked as a senior, principal and then Chief Scientific Officer, preceding his role as a director of the institute.
Announcement of global pandemic should usher in mass-scale planning to prepare for the mass-scale need for testing, treatment, and of course, unprecedented death. Unfortunately, nothing of that sort happened, because IEDCR "lacked the vision."
And that was the first mistake.
The institute's first response to the rapidly unfolding global pandemic was riddled with inconsistencies and raised several red flags; such as assigning itself as the only facility for Covid-19 testing, not reaching out to areas beyond Dhaka and being slow to respond to the pandemic in general. (IEDCR does not agree.)
It is imperative to try to understand the reasons behind IEDCR's failed first response. The institute is certainly not alone to blame, rather, the short-staffed, under-equipped, mishandled "fire brigade of health" is a symptom of a larger problem at play: a dilapidated healthcare structure and governance that has not allowed IEDCR to successfully operate for decades now.
And in the last 18 months, since the first Covid-19 death occurred in Bangladesh, preceding the 27,469 deaths (as of 29 September, 2021), not much has changed to alter our fate in the face of the next healthcare crisis.
The red flags
Even as late as 28 February, 2020, a specialised team of healthcare officials handpicked by the directorate general was discussing how to update the National Response Plan, which was a 2005 manual used to counter the threats of a bird flu pandemic (aka the swine flu) in 2009. Dr Be-Nazir was part of that team.
One of the several striking features of this planning process was the designation of only one institute as the testing center for the virus. Even though, at the time, there were at least nine other institutes in the city with functioning polymerase chain reaction (PCR) labs and capable scientists to carry out the tests, according to the doctor.
It baffled former officials too who worked in the institute. However, this decision was not taken by the IEDCR, but it was the result of a collective "higher management" directive.
In the beginning (late February 2020), there were some 700+ Personal Protective Equipment (PPE) in stock. The obvious pandemic response strategy should have included upping this number. There were offers from individuals, within the former IEDCR official group, that if necessary they would fund it.
On 4 March, 2020, an email containing the updated National Response Plan (for the coronavirus pandemic) informed Be-Nazir that only one institute will, in fact, carry out the tests and there was no plan to aggressively/instantly acquire more PPEs.
There were reports during the first Covid-19 wave of doctors refusing to treat patients without their own access to PPEs out of concerns of their own health safety. And yet, IEDCR did not pay enough heed to the issue.
"We lost many doctors and frontline healthcare workers in the first wave," said Be-Nazir, some of those deaths could have been avoided by the right protective gear provided at the right time.
"The virus will not come here," was a grossly misinformed and misguided belief that was uttered at meetings held at the government healthcare national level during the beginning (February last year), said a former IEDCR official.
At the time of the Swine Flu pandemic in 2009, the same institute, IEDCR, reacted much more proactively and attacked the source. At high alert, IEDCR teams went door to door to collect samples while taking all other measures for containment. Thankfully, the situation did not evolve into a real pandemic threat.
A pandemic cannot be stopped, but delayed with the right measures such as contact tracing, early diagnosis and isolation, said a former IEDCR official, requesting anonymity.
"I beg to differ, IEDCR responded promptly and effectively from the very beginning," said ASM Alamgir, Principal Scientific Officer of the government's Institute of Epidemiology, Disease Control and Research (IEDCR). "In fact, we worked presumptively."
From airports to ports of entry, we covered all our bases, he said. "In the beginning, when someone was getting Covid-19 tested in, let's say, Rangpur, the sample was sent to us and results were received within 12 hours," said Alamgir.
IEDCR has trained manpower all over the country at surveillance sites and when a patient was identified wherever in the country, the sample was collected and brought here to be tested.
In February of last year, IEDCR submitted a proposal to the government to expand the number of labs permitted to test for Covid-19. "And once the government approved it, we trained every lab [equipped to conduct tests] in the country to conduct the tests properly," said Alamgir.
Around the world and first pandemic response: Comparing notes
It was reported that following the World Health Organisation's recommendation of 22 January that countries begin considering containment measures, Mongolia immediately activated its inter-agency State Emergency Commission, with the support of the Ministry of Health, as a lead agency in the response against the coronavirus outbreak. The Mongolian government made an unprecedented decision to close all schools and kindergartens starting 25 January last year.
The Vietnamese Centers for Disease Control and Prevention, which had been developed and improved since the outbreak of SARS in 2003 and H1N1 in 2009, cooperating with the Ministry of Health, had promptly advised the government to achieve effective and rapid control of various items. And on 14 February last year, Vietnamese citizens coming home from abroad and foreign citizens arriving in Vietnam had to be quarantined for 14 days and get tested for Covid-19, according to various reports.
According to news media reports, when Covid-19 first became a real threat to Australia in March last year, the Federal government responded quickly closing international borders and implementing a mandatory home isolation program, even for returning Australian citizens. Police were dispatched to see people in quarantine were adhering to rules. The IEDCR of Australia is the Australian Health Protection Principal Committee, and it was on the same page as the government.
The underlying weaknesses of IEDCR
IEDCR is understaffed, under-resourced and under-funded. The Ministry of Health and Family Welfare (MOHFW) has two divisions called the Health Service Division and Family Welfare Division. Under the former is Directorate General of Health Services, which comprises Directors, hospitals and clinics agency, IEDCR, Institute of Public Health among several other institutes.
Every year, money allotted for the health ministry from the fiscal budget, trickles down this hierarchical structure.
"Before the pandemic, the institute got only Tk5-6 crore allotted to its name from the fiscal budget," said a current IEDCR official, who requested anonymity.
It is barely enough to pay for the cost of running the institute, he claimed. The institute receives funds from America's Centers for Disease Control and Prevention (CDC) and WHO too. However, the official claimed that these funds are not fixed.
During Be-Nazir's directorship, WHO biennial program fund for digital surveillance and response provided IEDCR with a few crore takas for one year.
"There is a procedure of getting funds from the government," said a former IEDCR director who requested anonymity. It takes time. For instance, the healthcare budget is already allotted for certain sections; and it is part of 5-year plans. "For us to get access to, let's say 'emergency fund,' we would have to declare it [the situation] as an emergency first," he further explained.
"That is why we see developed countries such as the US declaring a healthcare emergency at the time of need," he added. But an emergency was not declared in Bangladesh in March last year.
Research is the backbone of these institutions, say the public health experts, and a sure way to be able to mitigate health crises such as the coronavirus pandemic. Till date, IEDCR does not have a designated, separate research wing. There are eight major departments in the institute, including but not limited to microbiology, bio-statis, epidemiology, medical social science, etc.
One of the other factors to look at is the designation of IEDCR officials, which is, according to experts, not accurate. For instance, a virologist should not be placed in a leadership position. There are structural flaws and cracks in the institute that demand urgent attention and amendments.
"If you think about it, even the designation of the top officials or directors are baseless. Their specialty does not lie in epidemiology, but still they are assigned top positions in the institute, why?" asked Dr A M Zakir Hussain, a former Primary Care director, DGHS and also a former director at IEDCR.
"We also lack technical people in the ministry," Dr Be-Nazir said, which is why policies and pandemic responses reflect grave inconsistencies and failures. Possibly the only fact that both IEDCR and non-IEDCR officials agreed upon.
Dr ASM Alamgir, IEDCR Principal Scientific Officer, has been the person in charge of the Covid-19 unit and Dr. Meerjady Sabrina Flora, IEDCR director, was replaced by Dr Tahmina Shirin in August 2020.
While Dr Tahmina has barely ever made any public appearance for a media press briefing, her predecessor did not do much better either.
"It was interesting to see the sheer lack of a means of communication between IEDCR and the country at large," said Dr. Toufique Joarder, Vice President, Public Health Institute. Sure, Dr Flora remained visible in press media briefings during the first wave, but it wasn't nearly enough to sustain open communication channels.
Also, Toufique pointed out, where were other health experts of the country in the grave hour of need? Some of the most sought after public health specialists were nowhere to be found, according to him. Politics, perhaps, reigned, even then.
IEDCR is currently focusing on vaccination effectiveness by carrying out surveys. "We will follow up with those enrolled for two years from now," said Alamgir, "this is a continuous effort."
IEDCR, which suffers from a grave lack of manpower, has been receiving a lot of support from the government, said Alamgir. The institute has also submitted a proposal plan, around 3-4 months ago, detailing ways to improve its own capacities. "It is in the process of being reviewed," informed Alamgir.
The big picture
The institute should be well-equipped, funded and treated as such that it has the capacity and authority to direct and guide the government in times of health crisis.
It has to come from the "higher management," otherwise, regardless how many times and how many "directors" or officials come in to lobby to better IEDCR, it will continue to remain within the limited confines of incompetency. "The government can perhaps create a commission to implement the new changes," said Dr. Be-Nazir.
IEDCR should be up to the brim with the state of the art technology and equipment, research fund and manpower, "but take a walk around the building, the picture is grave," said Dr Be-Nazir Ahmed. By 18 months, "there should have been hundreds of scientists, medical technologists [in IEDCR]," he added.
