Insights and impact

What has your personal story been during the COVID-19 pandemic? Give any kind of details you feel comfortable sharing.

“My mom is 75 years old and she was isolated in Bangladesh due to COVID-19. This was horrible from our perspective because she was living alone. We were constantly in touch with her to make sure she was isolating and not coming into contact with people. After a couple of months, my sister who lives in New York and my brother who lives in Connecticut whose wife works as a schoolteacher, were affected. My brother’s wife got COVID and was admitted to hospital, the following day he was too. The children, 12 and 5, had to be left alone at home and could not come into contact with other people. This was a harrowing situation for us, especially tricky in the early days. I was talking to the nurse at the hospital three times a day to make sure my brother was stable and improving and he was at 90 percent oxygen. My brother-in-law would park outside in his car and sleep outside the house to make sure the kids were ok as well as leaving food outside for the kids. At the same time, we were talking to my mother, calming her down and reassuring her that we would survive the trauma. After two weeks, my brother and his wife were okay and were discharged from the hospital. Eventually they got the vaccine. We had two doctors in Bangladesh check on my mother to make sure she was ok. My wife’s mother is also around that same age, also alone in Bangladesh. My mom calls her mother twice a day to make sure she is okay. My mother-in-law also takes care of her brother who is 78, and is diagnosed with autism. There is a sort of bearing, mental strength associated with the extended period. This will have an impact for times to come as this trauma will result in an extended recovery time. Every family knows someone in their own family or close to them who has suffered. This is a story that has happened a hundred times over – the moral of the story needs to be told for us to understand the impact.”

How did it affect your country?

“In Bangladesh, the situation was pretty bad. The death rate is about 24 percent right now. We had about three waves, we are now in the third wave. The first wave was urban-based, the disease spread within urban environments from people who came from outside the country and airports. The third wave is caused by neighbouring people from India coming into Bangladesh and carrying the delta variant. The delta variant is spreading fast and the worry is that it will spread into the urban setting. About 9 million have been affected and about 14,000 have died. Infection is a relatively low number but we are still in the early stages. The stay at home order was issued from July 1st, shutdown and registration has not necessarily worked in the past but we shall see how it will work now. Bangladesh started with the AZ vaccine from the institute in India. That delivery of the vaccine has now been stalled due to the circumstances in India. India has stopped exporting the vaccine as they will use them for themselves. Bangladesh will likely get vaccination imports from China and maybe some Pfizer from the US. Vaccinations will likely not be the solution for Bangladesh. Schools have been closed since March 2020 and have no plans to reopen. There are industries like the garment centre which have remained open. The government announced some disbursement. People are thinking that the poverty rate will double. What is more worrying is the loss of the education rate for many people. Medicine requires education for society to advance. More than a year of school closure means the loss of education for our children. One, people are simply not learning. Second, as many people are not going to school, people are doing something else and drop out. Many children may be selling or peddling on the streets. Third, the rate of child marriage has increased. This is very dangerous as we are losing girls (women are the anchor of society). Say for example the father of a family has become poor, he has a 12/13-year-old daughter, someone makes them an offer, he takes this money to survive. This child becomes pregnant in the next year, may or may not survive, or faces a number of medical problems in the future.” 

What were some of your specific pandemic procedures and quarantine rules?

“The government has all kinds of rules that they post on their website. Most people (30-50 percent) get their information from the internet. Lately there are TV and radio announcements. In Bangladesh, people use microphones to announce isolation, the same thing they do with tornadoes/cyclones.”

How do you think the pandemic and school closures have affected girls and education?

“We are losing girls in the education system. The majority of the people that are dying are males (60 percent). However, the people that have been negatively affected are women. The education system tries to bring women to equality. When this system is not working it puts women behind. We have increased deaths, poverty, child marriages and mental health issues which all affect women. We know that being out of school makes people distressed from being out of school for so long, and we do not know what the severe mental health impacts will be.”

What kind of research has your team been doing throughout the pandemic?

“When the first case of COVID was reported in March 2020, I was following everything in the US on international news. I was also following the news in the US because I resided in Nebraska for 6 years and also Italy. I was looking at all the expert comments and stories. I assumed it was coming to Bangladesh because we had no border control. Nobody checked my temperature at the airport, there was some intervention where I had to declare if I was experiencing symptoms or if I had been to China. People very much panicked when the first case was detected in Bangladesh. The case rate went up and the first announcement I remember was on 18 March. Then came some prediction modelling by many organisations including John Hopkins. In Bangladesh, the Public Health Advisory Committee was formed to administer the eight divisions in Bangladesh. I was part of the N-95 mask ignition. Using Python code, I found a model I could use that predicted that Bangladesh would have 50,000 cases by the end of May 2020 even though we only had 2000 cases at that time, which told me that the situation in
Bangladesh would be very bad. Obviously, it was very hard to develop intervention in developing countries because of a lack of income. DGHS, a department in the Ministry of Health and Family Welfare in Bangladesh, shared this information from the model with the Prime Minister. This is basically how the prediction journey started. I was hosting that projection modelling on my personal webpage. My journey started with an intention to do something for the country and I figured out that no one was striking an intervention in Bangladesh, so it was my part to help. I tried to use my economic and mathematical knowledge to help, even though I am not an infectious disease modeller. We then switched to modelling with the CoMo Consortium. I also had a chapter published on free government COVID testing.”

How about personally? How was your family affected by the pandemic?

“My father-in-law and mother-in-law were both affected. My father-in-law was in the ICU for quite some time and is still in hospital. My mother-in-law also tested positive but was in our home and in isolation for quite some time. My three kids were away for two weeks at my sister’s house so that they could stay clear of the virus as my wife and I were visiting the COVID hospital almost every day. My wife and I did have COVID symptoms last year and in August. However, it was quite difficult to get tested. My doctor advised me to stay at home. My uncle died due to COVID two days ago. I have also seen many relatives affected, including my colleague’s relatives. Bangladesh is now experiencing a very difficult time with COVID due to our limited testing. Every day we have around 50,000 new cases and our testing is around 5000 a day, which is very limited compared to other countries. Bangladesh is now under lockdown until the 5th of August.”

How did the government respond initially to the pandemic crisis?

“I always tried to follow the lockdown rules especially because of the widespread vaccine hesitancy. It was very hard at first because the kids had to be kept away from their mom as she had to visit her father in the hospital. It was very hard especially because the living conditions in Dhaka are not ideal as everything is very crowded and dense in population. The government had measures to check how closely procedures were being followed. Strict lockdowns are heavily enforced. For three days you can see on Google that rules are being followed, but after a couple of days, people start following regulations loosely. Industry will be open on August 1st. The government could not remain strict for an extended period of time and has tried sporadically, it has been highly disorganised and inconsistent; it was practically impossible for the government to say that the infections would be solved in a week. The government also has taken a lot of contradictory steps, which is not helpful for compliance. They also did not make a priority of the virus itself, rather policy priorities lay in economics.”

How would you describe the mental stress impact on the youth situation in Bangladesh?

“COVID has of course affected us mentally and physically. Especially for young people, drug abuse has increased a good amount. Substance abuse, especially marijuana has increased, in which the youth has not really been interested in learning anymore. Overeating, especially with fast food, has increased, especially because of the lack of exercise. The sleep cycle has changed completely, young people have been using the internet, watching movies, and apps like TikTok more at night. The amount of time they are looking at screens has increased a very large amount. The financial crisis has affected us a large amount. Also, the amount of violence has increased which of course has affected the mental state of young people; they are seeing their mothers, sisters, fathers affected. TikTok has increased this violence because people will do crazy things to be recognised. Families have not been able to provide their family with smart devices because of the financial crisis, which has especially been harrowing since everything has shifted to a virtual level. Using apps like WhatsApp, Facebook, and Twitter is how we connect these days. The rise of unemployment has increased; many people have lost their jobs due to organisations going bankrupt.”

In terms of education, how have women in Dhaka and other parts of the country been affected?

“Child marriages have increased. The legal age of marriage is 18 but parents will often marry off their daughters at the age of 13 and 14. The purpose is it is considered as having less of a burden. Parents prefer their sons to be educated and not their daughters if they can only afford to send one child to school. Women being murdered has also increased during this pandemic due to the large amount of domestic abuse. This is a very common scenario happening in Dhaka and it makes it harder for things to change due to this being so normalised in parts of Bangladesh. Women can call 999-111 for help, which is an initiative Bangladesh is taking to counter domestic violence.”

Manar, what brought you to CoMo?

I learned about CoMo through Oxford’s alumni network – in April 2020, I attended a presentation of a new model developed by a team of public health researchers and mathematical modellers at the University of Oxford to analyse the impact of policy interventions on the pandemic.

At that time, there hadn’t been any cases of COVID-19 reported in Syria but there was concern that the disease would have a huge negative impact in displacement settings – in North West Syria there are almost 3.2 million internally displaced persons and in North East Syria around 900,000.

Although there are many models available world-wide, I favoured using the CoMo model as the framework is based on a participatory approach and close collaboration with policymakers – this is crucial in a setting where the health governance is fragmented and there is limited public data available. Also, the continuous support provided by the technical team and other members within the consortium is invaluable as is the exchange of knowledge and expertise with modellers in low- and middle-resource settings.

How did you set up the teams?

We have two modelling groups in Syria: one for the North West of Syria and one for the North East.

In May 2020, I presented the CoMo model to policymakers in North West Syria and, through snowballing, I formed a team of six local health experts. The team includes the Director of the Health Information System Unit for North West Syria (HIS), the CEO of the Relief Experts Association (UDER), the Coordinator of the Early Warning Alert and Response Network/Assistance Coordination Unit (EWARN), the Coordinator at the American Relief Coalition for Syria, and a clinician at Bab Al-Hawa Hospital.

In November 2020, we established the COVID-19 modelling group for North East Syria. This collaborates with the Kurdish Red Crescent and Self Administration health authority – the latter provided us with access to COVID-19 cases and mortality figures while the task force helped in contextualizing the parameters in accordance with the context of North East Syria. 

Tell me a bit about the work you do?

My work is primarily with the local CoMo team in North West Syria. The policymaking process is fragmented in North West Syria following years of conflict but we are successfully engaging with policymakers in the health and education sector. We have presented our findings to the National and International Task Force and we have addressed questions from the Interim Ministry of Health regarding the impact on the epidemic of opening schools. The CoMo modelling findings are used by NGOs, such as UDER, as a tool for advocacy for increasing the coverage of wearing face masks in Northwest Syria.

What are your main challenges?

COVID-19 has helped us as modellers and public health practitioners to better understand the healthcare system in North West and North East Syria. Fragmented health governance and decision making was clear from our early discussions around parameters for the model: when we were thinking about scenarios and non-pharmaceutical interventions, we had to be mindful of who would be implementing COVID-19 measures. To help with this we created a process map for decision making – we ended up with over 10 decision makers with conflicting interests and priorities. 

Another challenge is the disempowerment of local healthcare actors. For example, when we started presenting our findings to the Ministry of Health, we were referred to external organisations such as the World Health Organisation, The United Nations Office for the Coordination of Humanitarian Affairs etc. for approval – local policymakers felt they didn’t have the power to implement any measures without approval from external donors.  

We have also noticed a pattern of prioritising no-cost interventions. School closure is one of the key interventions that we are requested to model as it is perceived as the least costly to implement but it is not without cost – indeed, in Syria’s context it can have a drastic impact on children’s development and protection.

Why is modelling important in the Syrian setting?

Modelling supports the decision-making process by providing policymakers with evidence-based data so they can weigh the pros and cons of different mitigation measures. This is particularly important in situations where measures could have negative unintended consequences – with school closures for example. According to UNCIEF over 2.1 million children have dropped out of school since the start of conflict in Syria. Modelling enables policymakers to weigh the impact of this type of intervention on both COVID-19 and children’s education. This is especially important in a society where being prevented from attending school could expose children to risks of recruitment in armed groups, domestic violence and early child marriage.

Another important example is that modelling enables us to project the impact of COVID-19 on hospital occupancy. This is crucial in limited settings – the health system in Syria is functioning on half, if not less, of its capacity and modelling has help us to predict the trajectory of infections and the likely number of hospitalisations which is crucial information in limited settings.

What achievements are you and your team most proud of?

There have been other models used within Syria during to project the impact of COVID-19 on the Syrian healthcare system but to my knowledge, our modelling teams are the only ones working in close contact with local policymakers and health staff in the field. 

What has been heartening is that the modelling we’ve been doing has created a common ground for different conflicting parties. It has enabled us to simulate different scenarios using a combination of non-pharmaceutical interventions such as an international travel ban, school closure, handwashing, facemask wearing, social distancing, and working from home. Having the data that we can demonstrate visually to policymakers has enabled us to have meetings to present findings and these have been followed by discussions to improve the model inputs. It has been so rewarding to see policymakers use the findings for strategic planning: the findings from our modelling influenced the annual strategy plan for the COVID-19 task force in North East Syria and the health minister of the interim government used our outputs in his public engagement.

Modelling is a new concept in many countries including Syria. Establishing the modelling team in North West Syria has helped our team members to develop their capacity in modelling and evidence synthesis. It has given us the ability to combine scientific evidence relating to the COVID-19 pandemic with model projections and to present findings to policymakers and external donors. The team’s knowledge has been further enriched through sharing of knowledge through the participatory nature of CoMo and through interaction with teams in other countries such as Bangladesh, Kyrgyzstan, Afghanistan and Iran.

What are your hopes for modelling in Syria?

I am passionate about building the capacity of local health staff in modelling. Before the pandemic there weren’t many Syrians with skills in mathematical and pandemic modelling. COVID-19 has given us the opportunity to develop a skill base within the country and I’d like to see it develop further still as it will be crucial not only to see out the pandemic but also in supporting efforts to mitigate other infectious disease beyond COVID-19. 

We also hope that through our modelling work we will be able to use the CoMo model to build common ground for Syria’s four health systems. So far, we have managed to go some way to establishing this in the North West and North East Syria. 

If we could continue with the trajectory we’ve established – building our modelling capacity, establishing common ground for our healthcare systems, continuing to engage with policymakers and drive through change, bringing the strengths of collaboration and participation and knowledge exchange to the way we work – Syria would be in much better position to countenance the healthcare challenges of its present and future.