Why we must equip the informal health sector to fight Covid-19
Nikhil Bishwas has a small chamber in a large village market called Bongobazaar in Netrakona, cozily located behind a pharmacy run by his nephew. He is a balding man in his 50s, with a warm and innocent smile that almost invites you in.
He has been practicing for 36 years, and to his community, his is the first and last word for most health problems. He starts his practice sharp at 10 in the morning, and it is not unusual for him to return home to his sleeping family well past midnight.
It is also not uncommon for his chamber to overflow with patients. But over the last two weeks, something has been different. Nikhil has been flooded with over 50 patients a day with fever and cough-like symptoms, much greater than usual.
He is acutely aware of the coronavirus pandemic ravaging other countries, and that hundreds of people have come back to the locality from Dhaka or abroad prior to the lockdown. He doesn’t have any protective equipment, and has not received any briefing or training about coronavirus, so he uses a makeshift cloth mask and continues his practice. He is afraid he may soon contract the virus, but that doesn’t stop him from fulfilling his deeply felt duty towards his community.
Almost as if justifying and comforting himself, he meekly ventures that this sudden spike of fever and cough is most likely just the seasonal flu.
By all counts, Nikhil is a hero. Just as much as the brave doctors and nurses risking their lives fighting the Covid-19 crisis in Bangladesh, and indeed across the world. But you will never hear people like Nikhil be glorified, simply because he didn’t have the luxury of a medical education.
He is one of tens of thousands of non-graduate practitioners, generally called “village doctors,” who are spread across every nook and cranny of Bangladesh, and continue to serve people where other more qualified forms of health care just aren’t available.
No one knows their real numbers. But many of the 200,000 pharmacies in Bangladesh, and especially those in poor slum or rural areas, are also practitioners. Meaning they don’t only sell medicine, but also recommend them to the vast majority of patients who show up without doctors’ prescriptions. In the absence of formal education, they make do with a combination of apprenticeships, diplomas, certificate courses, and sheer experience.
Many have been in this vocation for generations. Research by ICDDR,B has found that up to 70% of people in Bangladesh go to a pharmacy or village doctor as their first point-of-care.
Despite their widespread presence and popularity, it has proved very hard to formalize and integrate them into our health system. The health sector and policy in Bangladesh has ignored and refused to mainstream them, largely with the positive intention of protecting patients from malpractice.
But this has done nothing to diminish their popularity; instead, it has only driven them to the shadows and the lack of training has resulted in poor quality advice and treatment for millions of poor patients.
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This refusal to train existing, trusted resources is bad enough, albeit understandable, during normal times. But in the war against Covid-19, this could be a catastrophic mistake. Imagine if one of Nikhil’s patients was indeed infected, and Nikhil got exposed. Within a couple of days, without showing any symptoms, Nikhil would become infected, and any of the 80 or so patients he touched every day would be at risk of infection. Over the course of the next 10 days, until Nikhil develops symptoms severe enough to keep him in bed, he could have infected as many as 500 people.
Without proper training on safety and infection prevention, and minimum supplies of PPEs, the tens of thousands of village doctors across the country will act as transmission supernodes, and undo much of the efforts and sacrifices of the government in controlling this epidemic.
Conversely, they also represent a tremendous opportunity. Whether we like it or not, patients will come to village doctors days or even weeks before they show up at a hospital. Imagine how much advantage we could gain if we could keep them in sync with the government, and use their trusted voices to amplify the facts, educate people, and increase compliance, rather than letting them and their patients fall victim to the rampant rumours and panic.
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In Bangladesh, we don’t have a perfect system. We have insufficient doctors, underequipped hospitals, and limited budgets. But we do have tens of thousands of dedicated people like Nikhil across the country. They are not our enemies -- they are fellow soldiers in the same noble fight against disease and misinformation. In this war, we will either fight together, or die together.
Let us not make perfect be the enemy of the good, and urgently prepare and equip them as the infantry in this battle of a lifetime.
Rubayat Khan runs Jeeon, a social enterprise upgrading pharmacies. He is currently working to equip pharmacies to combat Covid-19 in their communities.