This telephone-based mixed-methods study revealed a lack of preparedness at every step of the Bangladesh health system's COVID-19 response in the initial weeks. Findings reveal the concerns of the FLWS of getting infected, self and family members, from the poor covid response of the health system; continued shortage of PPE and other protective supplies, fatigue from overwork and inadequate rest, lack of incentives such as dedicated accommodation and transport for those working at the covid hospitals, and mental health consequences of these factors combined. The implications of the findings for rapid, appropriate and effective response is discussed.
Inadequate health system response to COVID-19:
From the detection of SARS-CoV 2 in China in December 2019 to detecting the first case in early March 2020, Bangladesh got more than two months to be prepared to face the pandemic in a densely populated LMIC. Health systems were the least prepared among all sectors of the Government. As a result, there was a lack of protective gears such as the PPEs; if present, FLWs were not satisfied with the quality of the PPEs. There was also a lack of training on COVID 19, donning and doffing of PPE, and proper infection and prevention control facilities in the hospitals and other health centres. As a result, in the initial period, the pandemic's mismanagement resulted in many casualties among the doctors and other FLWs.
Along with some other factors, the FLWs with inadequate and inappropriate PPEs had an increased risk of COVID 19 compared to others . In the early days of the pandemic, a global shortage of PPE was observed . Many countries that were hit hard by COVID 19 in early 2020 also reported a deficit of PPE, fatigue of the FLWs etc. By the end of February 2020, more than 2500 FLWs were positive in China , where the shortage of PPE and FLWs' prolonged exposure to infected patients were among the reasons . By mid-March, around five thousand Italian FLWs (9% of the total case) were infected . Around one-fifth of the nurses in a South Korean health facility resigned by the 1st week of March 2020, another hospital pleaded for emergency reinforcement of the FLWs . But unlike Bangladesh, these countries did not get the lead time of two months to be prepared and were hit badly even before understanding the disease. Incidentally, Even the Joint External Evaluation (JEE) (mandated by International Health Regulation 2005) Bangladesh Mission report 2016 indicated that the country was poorly prepared for an epidemic . The haphazard situation of the health sector is a reflection of that evaluation.
The mental health of the FLWs
Mental health is an important indicator that showed a slight improvement in the follow-up round concerning several indicators. The participants mentioned gradual mental health deterioration as they had symptoms like panic, anxiety, irritability, frustration, and insomnia. On top of that, since they are uncertain about the protective gears they are being supplied with, fear of infecting their family member was an additional irritant.
A cross-sectional study from Dhaka Medical college hospital, among the physicians dealing with pandemic incidents of insomnia and symptoms of depression and anxiety, was observed . Depression, stress, anxiety, and post-traumatic stress disorder (PTSD) was found prevalent among all the health care workers (HCWs) of Singapore contemporarily . A systematic review also reported anxiety, depression, and stress among HCWs of varying prevalence across studies . Underlying reasons for the HCWs' mental health problem was found to be exposure to COVID 19, being women and worries about infection or infecting others- was reported by another review . Even WHO addressed this grave problem by issuing several guidelines so that HCWs can support themselves and be supported by society .
FLWs' suffering while confronting the pandemic is a recognised global phenomenon. But addressing the problem has to be done locally, in a culturally sensitive way. Mental health is one of the least prioritised areas in a densely populated LMIC like Bangladesh, let alone the mental health of the HCWs. As a result, the pandemic's immense pressure took a toll on the psychology of the FLWs. However, a regular lesson on stress management for this high demanding sector could have played some preventive role initially, but not for the long run. It is of paramount importance to keep those healthy who keep the whole society healthy.
The necessity of a strong public health sector: Lesson for a way ahead
The poor covid-response displayed a low priority given to public health in Bangladesh. During the SARS outbreak in 2003, 41% of the total cases were health workers . Singapore enhanced the capacity and capabilities for pandemic preparedness since then, including stockpiling PPE at the national level for protecting their FLWs from the next disease outbreak, such as the current COVID-19 . As a result, by mid-April, only 1.7% of cases were HCWs, having family/household as the most familiar source of exposure . Along with this measure and is one of the highest COVID 19 testing states of the world with the mandatory mask-wearing provision, Singapore had only a 0.05% mortality rate by September 2020, below the global average (3%) .
Vietnam, another Southeast Asian country with a long, porous Chinese border, took rigorous measures to control the spread right after China first acknowledged COVID 19 . As a result, they had fewer COVID 19 morbidity and mortalities, among which very few FLWs were tested positive [32, 33]. Strong government leadership with effective multi-sectoral collaboration, a robust response system, and WHO's support for strengthening health emergency response after previous epidemics are lessons from Vietnam .
Because of a solid public health system, the HCW and general population of the above two countries did not suffer much from COVID 19 despite being in the vicinity of Wuhan's primary epicentre. Bangladesh should learn from this experience and move forward to strengthen the public health system for preparedness, early warning and prompt response to any future outbreak.
The survey was conducted on a purposive sample of a limited number of FLWs within a short time. However, data were collected from quite some different areas as an attempt to avoid potential bias. Though not generalisable, we think this gave enough diversity and may help policymakers make decisions. Moreover, the study was conducted at the height of the outbreak in Bangladesh, limiting the findings' generalisation.