Coming to terms with COVID-19 personally and professionally in Bangladesh
Authors: Senjuti Saha
Journal: The Lancet Global Health (2021)

As I put together the last few slides for a Zoom seminar in Canada while sitting in a room in Bangladesh, I felt feverish. I took 400 mg of paracetamol, blaming it on the exhaustion of giving talks at odd hours, and little proper sleep. It was late March, 2021, and COVID-19 cases had started to rise in Bangladesh again, which meant more guidelines to keep my hospital team safe, more testing for my laboratory team, more genomic sequencing, and also more infections within the teams. The stress was beginning to accumulate, just like it had in March, 2020. I blamed the stress. I felt dizzy as I answered the final questions after my talk around midnight and started losing my clarity of thought. "I really need to get some sleep tonight," I thought. But despite being extremely tired, I could not sleep. Feeling worse every passing minute and not being able to sleep the entire night, I decided to get tested for COVID-19 as soon as my hospital team was at work. By 0900 h, I was too tired to get to the hospital to give a sample, so a nurse from my team kindly came by to obtain a sample and drop it off to my laboratory (a privilege of being part of a testing laboratory). By then I was getting worried, more for my parents who I live with, than for myself. Because I leave the house for essential work, I always wore a mask at home and ensured my parents wore a mask when I was at home. We only met on our open terrace, and never ate together. I did everything possible to keep them safe, but a deep worry could not be brushed away. So, when the nurse came by to take my sample, I requested that they take samples from my parents too. I finally fell asleep later that morning. At 1600 h, my colleague woke me up and began by delivering the good news before changing the topic to molecular biology. "Sir and Madam are negative. You are positive. Your cycle threshold (Ct) value is 9. We used the Thermo Fischer kit and we detected amplification of the S gene, so it is not the B.1.1.7 variant."1Brown AK Gubbay J Hopkins J et al.S-gene target failure as a marker of variant B.1.1.7 among SARS-CoV-2 isolates in the Greater Toronto area, December 2020 to March 2021.JAMA. 2021; 325: 2115-2116Crossref PubMed Scopus (65) Google Scholar The number of cases and deaths were surging in Bangladesh, and my team were doing the genomic surveillance for SARS-CoV-2 variants.2Saha S Malaker R Sajib MSI et al.Complete genome sequence of a novel coronavirus (SARS-CoV-2) isolate from Bangladesh.Microbiol Resour Announc. 2020; 9: e00568-e00620Crossref PubMed Scopus (25) Google Scholar, 3Saha S Tanmoy AM Hooda Y et al.COVID-19 rise in Bangladesh correlates with increasing detection of B.1.351 variant.BMJ Glob Health. 2021; 6e006012Crossref Scopus (18) Google Scholar I immediately requested that my colleague does not tell the rest of my team as they would be concerned. My father and I run a non-governmental organisation with more than 300 workers whose livelihoods depend on us. My father is older than 65 years, and I have a complex medical history, which includes cancer. I had to ensure that my parents stay negative and that I protect the morale of the team. I do not remember much of the next few days. I was tired, I had fever, and my eyes hurt so much that I could barely use them. My mother set up a little table in front of my room. The first thing she left there was a pulse oximeter. Every few hours, she would write on our "Saha et al" WhatsApp group asking for my oxygen saturation. 1 week went by. I sometimes slept during the day and sometimes during the night. I do not remember that week much, but I often wrote to my colleague and friend in Stanford who treats patients with COVID-19 in the USA. They asked for details of my symptoms and sent me papers, data, and summary advice on what I should do. They lamented that it was unfair that I got COVID-19; they thought that with my medical history and my profession, I should have been vaccinated. I laughed when my friend said "if you were here, we could try to get you monoclonals". My oxygen saturation never fell below 96%, and I did not have much difficulty breathing. 2 weeks passed by. I started attending some meetings but I was constantly worried. I did not leave my room. My parents left small meals by the door, which I opened slightly while being double masked to bring them in. I returned my used dishes heavily showered with 70% isopropyl alcohol. I was grateful, for the first time in my life, that my partner lived 5000 miles away. After 2 weeks, I tested positive again. My team sequenced my sample. "Ct 9 is not normal—which variant is this?" they later told me they had thought. It was the B.1.351 variant, the one that the world and our team had just started learning about. My worries were aggravated. My parents had received the first dose of the AstraZeneca vaccine; however, a manuscript from South Africa on medRxiv (now published in The New England Journal of Medicine)4Madhi SA Baillie V Cutland CL et al.Efficacy of the ChAdOx1 nCoV-19 Covid-19 vaccine against the B.1·351 variant.N Engl J Med. 2021; 384: 1885-1898Crossref PubMed Scopus (799) Google Scholar showed the vaccine's inability to protect against the mild to moderate COVID-19 caused by this variant, and data on its ability to prevent severe disease was still pending. It felt like I was in a movie, in which I had a bomb tied to me. One wrong move, and I could cause serious harm to my parents. There was no way I would leave my room. On week 3, I tested positive again with little apparent change in viral load, but I had started to feel better. However, the effect of reduced sunlight and being locked in a small room with little opportunities of movement started to appear—eg, backaches, white spots on my nails, and worsening circadian rhythm. My friend from Stanford prescribed a mandatory daily dose of sunlight. As a family, we decided that my parents would stay in their room with their door closed, while I sat on the terrace for 30 min every day. My cough suddenly worsened and talking became almost impossible. I had just started attending meetings, but soon they became unbearable. I started experiencing lapses in memory—I would be talking, and suddenly would be completely lost. I would be staring at a Word document for seconds, trying to determine how to save it. Finding the unmute button on Zoom became an embarrassing struggle. I cancelled my upcoming talks and meetings, and my sent folder filled up with emails of apologies. I am on week 5 now and I am recovering. Every day is a little better than the day before; I am learning to manage my brain fog and not be upset at my new disabilities at the age of 34 years. But a deep pain in my chest has not subsided. Perhaps it is from the virus inside my lungs, perhaps from the constant fear of spreading the virus and hurting my parents, or perhaps from the constant news of deaths around me. As upset as I am that I caught the virus, this experience has provided me with, yet again, more ammunition for the fight I started in Bangladesh—the fight against the deep inequities in global health. As I continue to recover from COVID-19, my team must continue to provide patient services in our hospital laboratories and run other surveillance studies. The burden of infectious disease is high in countries like Bangladesh even without COVID-19. With the dire funding situation in low-income and middle-income countries, it is difficult to not feel pressured by colleagues from high-income countries to continue some research projects that might not be of priority now; however, it is important to remember that health comes first. Sometimes, it is difficult for scientists in high-income countries to realise the hardships faced by those trying to do similar work in low-income countries, but the scientists in low-income countries must show determination, and voice their community's concerns. Many of my team members have already tested positive for COVID-19, and I am working hard to ensure that not a single person comes into work for any project, any study that is not essential, and that is not related to patient service, no matter how much that reduces our future funding prospects. When my Bangladeshi colleagues or I are forwarded forms from the International Committee of Medical Journal Editors asking us if we fulfil the requirements for being authors on a manuscript, I will clearly communicate to my collaborators from high-income countries that risking our health to implement and run a study and gather data (during a pandemic, an epidemic, or endemics) qualifies as substantial intellectual input. 15 months into the COVID-19 pandemic, the world has eight approved vaccines.5Zimmer C Corum J Wee S-L Coronavirus Vaccine Tracker. The New York Times.https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.htmlDate accessed: April 24, 2021Google Scholar But inequity in access to vaccines due to barriers caused by intellectual property rights and pharmaceutical profits in high-income countries has ensured that countries like Bangladesh will not have access to enough effective vaccines to meaningfully prevent future surges in COVID-19. Intellectual property rights and pharmaceutical profits have meant that my colleagues and I continue to risk our lives to conserve our livelihoods, like many others in Bangladesh. But how did the country get here? Bangladesh played a notable role in smallpox eradication by manufacturing the smallpox vaccine in a government facility. However, Bangladesh no longer produces vaccines.6Saha S Pai M Can COVID-19 innovations and systems help low- and middle-income countries to re-imagine healthcare delivery?.Med. 2021; 2: 369-373Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar The country must come together and ensure that it is self-sufficient and that people can protect themselves without petty donations. A new framework is needed in which all countries, especially low-income countries, have their own local vaccine manufacturing capacity and that different vaccine designs are openly shared between them. The world is at a pivotal moment in the fight against this pandemic. For the past 15 months, the world was in this pandemic together, but as I see lockdowns being lifted in high-income countries and vaccination drives in progress (with occasional hiccups and complaints), daily COVID-19 numbers have hit an all-time high with countries in Latin America and south Asia being the worst affected. These countries will get through this wave. But I worry that as 2021 continues, the situation will continue to get better in high-income countries while low-income and middle-income countries will go through a fourth and perhaps a fifth wave, decimating the countries' economies and eroding the progress made against poverty and disease over the past 30 years. I also worry that researchers will focus on the variants that present in their countries, and companies will design booster shots for the richest countries before producing vaccines for the rest of the world. As a result, the perpetual cycle of inequity in global health will continue. I am not writing this Essay because I am trying to inspire people to join the decolonisation movement. Rather, this is an attempt to inspire my peers and policy makers in low-income countries to take a step back, see the uneven playing field, and see the effects of our actions (or inactions) on our personal and professional lives, and our health. I am writing this Essay with the aim of bringing acknowledgment to the fact that all lives are not treated equally in this world. COVID-19 is not going away on its own and low-income countries cannot expect to be rescued from this or many of the other problems. As for me, I am working on combining all the SARS-CoV-2 genomes sequenced in Bangladesh throughout the pandemic while procrastinating by writing this Essay. Looking at the phylogenetic tree of the B.1.351 variant fires a sharp pain through the back of my head. I need to get better soon, it is a long road ahead.