[Dialogue] ‘Strict nationwide lockdown is essential for Bangladesh’

Dr Rajiv Chowdhury, an associate professor and the scientific director in Global Health Epidemiology in Cambridge University, UK, recently published a paper that predicted intermittent lockdown could reduce the transmission rate of Covid-19 significantly. In an interview with Dhaka Tribune’s Kohinur Khyum Tithila, he talked about designing a locally tailored lockdown approach in Bangladesh, the effectiveness of zonal lockdown, and more.

Your paper predicted if intermittent cycles of 50-day suppression and 30-day relaxation measures are imposed in Bangladesh, the number of Covid-19 cases and deaths is going to drop significantly. However, do you think a lower-middle-income country like Bangladesh can enforce this kind of intermittent lockdown?

At this moment, none of the other options (like zonal lockdown or loose mitigation) is likely to work in Bangladesh to reduce the infection and death tolls. If we want to save lives and prevent hospitals/ ICUs from overflowing, the only way, in my opinion, would be to enforce some form of generalized strict lockdown for some time.

Our 50-day-on/30-day-off cycle was only an illustration for 16 countries. Our main message actually in that paper was to demonstrate the beneficial role of the strict rolling lockdowns (which can be applied and lifted periodically) as an option to reduce the numbers of deaths and hospitalisations significantly. This also lets the country open for business intermittently, so is particularly suited for poorer economies.

Specifically, they are relevant to Bangladesh, where: 1) the public health system is historically underfunded, vertical, and often poorly coordinated (so won’t cope, if there are millions of Covid-19 cases within a very short time), 2) infection incidence is very high and the population is very dense (so making standard contact-tracing based containment approach very difficult to implement) and 3) generalized testing and reporting capacities are very poor (making zone-based lockdowns also very difficult to implement and sustain).

Do you think zonal lockdown will help control the transmission rate? What are your thoughts about zonal lockdown?

Zonal lockdowns, if implemented properly, can reduce transmission rates in a specific area where you have a sudden cluster of the outbreak. However, when you have an entire country affected, with outbreak clusters present in almost every district, it becomes very difficult to implement and manage zonal lockdown.

Also, in Bangladesh there are other challenges: 1) there is no nationwide population surveillance system based on randomly-selected individuals, and 2) poor testing laboratory facilities and reporting capacities. Both of these deficiencies limit Bangladesh’s ability to continuously monitor the rates in real-time in the whole country (which is what is needed for, say, converting a yellow zone to red, or a red zone to yellow).

There are also logistical difficulties in zone management, control of movement in and around zones, and overall compliance (there are reports of people moving freely between zones). Looking at India and other countries where such a system has been tried, my view is that it won’t work in Bangladesh to effectively reduce the infection rates or deaths.

You said lockdown has to be locally tailored. Can you tell exactly what kind of lockdown approach is suitable for Bangladesh?

I do believe that strict nationwide (or at the least, big region-wide) lockdown would be essential in Bangladesh. Now, the duration and frequency of this lockdown can be determined by the policymakers in Bangladesh, according to what best suits the population and businesses, and according to the reduction of infection counts.

For example, WHO has recently recommended Pakistan also adopt a rolling lockdown to control their increasing epidemic, but through a 14-day-on/14-day-off cycle.

For Bangladesh, given the current high community transmission, I would suggest at least a few 28-day-on/28-day-off strict lockdown cycles.

The policy-makers can take the final decision on how many such lockdown cycles should be imposed, depending on local scientific feedback on the epidemic trajectory and by consulting with local communities/businesses.

The number of tests is still low compared to the population size of Bangladesh. Do you think it is possible for the authorities to map out a more discerning lockdown approach when there is not enough data?

As I mentioned, the current testing numbers are inadequate in Bangladesh. It is only about 380 tests per 1 lakh people at the moment. We need to have at least five times more tests than that.

Also, in Bangladesh, the testing approach has so far been focused on “purposive” and mainly self-referred samples; so, we have significant selection bias in terms of who is being tested. This approach doesn’t give the picture of the true extent of disease in the whole country.

Therefore, in the absence of generalized testing data (collected from randomly-selected groups of people from the entire country), simple zone-based lockdowns won’t work, unfortunately.

Do you think the policymakers in Bangladesh made the right decisions when Bangladesh was on the second stage?

Policymakers take policy decisions based on many considerations, and so I can’t comment on their earlier decisions. But to be fair, tackling Covid-19 has been difficult for all governments worldwide. I fully sympathize with the policymakers who have to balance between protecting lives and livelihoods.

But, I would say that strict isolation of the initial cases (eg, incoming migrants) and quarantining of their contacts could have been better in Bangladesh. Also calling the initial lockdown a “general holiday” perhaps made people less compliant to strict lockdown measures properly, and then lifting the lockdown prematurely, when the infection rate was still rising, was also not the best decision.

However, what is done is done, and therefore is now less important. What we do from here onwards should be of crucial importance and the main focus. I genuinely believe that Bangladesh can still turn this situation around if the sensible scientific options are taken. Our policymakers are capable of this.

Any recommendation for the policymakers in Bangladesh?

First, we all need to appreciate that saving lives and saving economies are both equally important for a country. In a country which is riddled with a life-threatening disease, where deaths are high, and people are always stressed for a constant presence of uncontrolled epidemic, it is very difficult for the economy to thrive in such a negative environment even if you keep all businesses open.

Also, if a country is a known global hotspot for Covid-19, it may turn other countries off to allow travel or to do business with that country, therefore drying up the orders to hurt the economy. So, protecting the health of the people and the workers will be vital for any economy to cope and gradually recover.

I agree that strict lockdowns are economically difficult for many people, but not having them doesn’t help the economy (or health) either in the long-term. Sweden and Brazil are classic examples of that, where both lives and livelihoods have been negatively affected by not controlling Covid-19 properly through the strict lockdown.

In a war-like situation, where we are constantly fighting with an invisible enemy, we have to have some flexibility to endure some short-term economic hardship in order to revive the health of the nation. These are not normal times.

So, in my scientific opinion, it will be sensible to have some form of strict (even if for short-term) lockdown to control the disease immediately. When this strict lockdown is in progress, some “key businesses” (such as those in the financial sector, pharmaceuticals or RMG factories delivering medicines or PPEs) can be considered as exceptions and should be allowed to run with proper workplace preventive measures put in place. However, the policymakers, of course, need to take the final decision on these matters.

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