Bangladesh has a health crisis in the making. The lack of preparation in the United States and Europe that has spawned the ongoing crisis there still exceeds the preparedness of developing countries such as Bangladesh, which will have to battle the COVID-19 pandemic with limited financial resources and a legacy of poor healthcare infrastructure, especially for the urban poor. Already one of the most densely populated countries in the world, Bangladesh also has thousands of stateless Rohingya housed in sprawling refugee camps in the southeastern region of the country, in conditions prime for rapid spread. Given its proximity to China and a large migrant population living in severely affected countries such as Italy, Bangladesh's Ministry of Health and Family Welfare should have taken preventative measures when the Chinese government first shared news of the deadly virus. Unfortunately, precious time was squandered.

After the first reported death in Bangladesh from COVID-19, there was a mass religious gathering in the southern part of the country attended by tens of thousands of people. Such events have been discouraged by authorities but communications need to be clearer and more forceful to be effective. Currently there is a ten-day nationwide holiday from March 26 to April 4, during which the army is enforcing social distancing across the nation. There are several potential policies the Bangladeshi government can use in its response strategy to blunt the COVID-19 pandemic's health and economic impact on Bangladesh.

The current situation

The Bangladeshi research institute spearheading the fight to test and detect coronavirus is the Institute of Epidemiology Disease Control and Research (IEDCR), a body under the Ministry of Health. The IEDCR has recommended that citizens avoid mass public gatherings. Yet, for the March 17 birth centenary of the country's founder, Sheikh Mijibur Rahman, the government arranged two major public events in Dhaka. These events were supposedly more scaled down from their original intended size, but even so they was still packed with thousands of celebrants, live music, and fireworks.

Unlike in neighboring Nepal where the army set up a quarantine facility in Kathmandu as per the World Health Organization's (WHO) recommendation upon the first positive COVID-19 test, the handling of quarantine measures in Bangladesh was inadequate. When the first batch of mass returnees arrived from China in February, they were all quarantined at the Ashkana Hajj Camp in Dhaka. The returnees complained about subpar conditions, including poor hygienic conditions and being crammed in small spaces. However, the authorities ignored the situation and the health risks it posed to those in quarantine. Subsequently, in mid-March when the second batch of foreign returnees-over a hundred and forty Bangladeshis evacuated from Italy-arrived, confusion ensued when they were taken to the same inadequate quarantine spot. These returnees protested and were ultimately allowed to leave with the promise of "home quarantine."

On March 18, tens of thousands of people gathered in Raipur in the southern district of Lakshmipur to pray "healing verses" from the Quran. This event was organized by an influential local religious leader who urged people to join this event, promising a way to be "free from the coronavirus." The same week, school holidays were announced to support the quarantine, but domestic tourist destinations such as the coastal areas of Chittagong and Cox's Bazar were all bustling with people and activity. On March 20, the Islamic Foundation allowed congregational prayers to go on albeit for a shortened length.

Such contradiction in policy guidance and lack-luster enforcement has wasted precious time for the government to shore up its limited public health system and to implement best practices for maximizing social distancing and minimizing community transmission of the novel coronavirus. The impact on Bangladesh's economy due to these missteps is likely to be significant.

The Asian Development Bank (ADB) estimates that export industries will suffer and the country will lose 1.1% of its gross domestic product (GDP) growth due to the pandemic. The ready-made garments sector which accounts for more than 80 percent of Bangladesh's manufacturing income has already suffered a loss of $3 billion as major export destinations such as the United States, United Kingdom, and European Union are cancelling orders. In addition, foreign remittances representing over 5 percent of GDP (close to $17 billion in fiscal year 2019) will be affected as half a million migrant workers have returned home since the outbreak. The majority of these migrant workers were based in Middle Eastern countries which have been hit by declining oil prices. Furthermore, daily wage laborers, such as rickshaw-pullers, are the hardest hit as the closure of schools and colleges have led to lower demand for their services. For these workers-who survive hand to mouth daily-the consequences of quarantines and lockdowns, however medically necessary, are dire without robust government provision of food and supplementary income.

Some encouraging news

Bangladesh's government is hardly alone in not tackling the pandemic early enough. Fortunately, after a slow start, the government has begun to show signs of urgency. Following the mass religious gathering in southern Bangladesh, the government started enforcing social distancing measures. Local administrations have been told to punish violators of the home-quarantine rules in line with Section 269 of the Penal Code. Additionally, an emergency lockdown has been imposed in the sub-district of Shibchar since March 19 where many returnees from Italy are based. The general secretary of the ruling party Awami League, Obaidul Quader, said that in the future there may be a possibility of further lockdowns in other areas. Most recently, the government declared a ten-day nationwide holiday from March 26 to April 4, wherein all government and private offices have been closed, and with the army mobilized to enforce social distancing across the nation. Almost all international flights have been suspended until April 7 and the country's March 26 Independence Day celebrations were subdued.

The government encouraged low-income people to return to their villages where they would be provided with government aid or to take refuge in Bhashanchar, an island in the Bay of Bengal originally built to house Rohingya refugees. On March 20, the government authorized the Bangladesh Army to run two quarantine centers in Dhaka. One quarantine facility remains the same Ashkona Hajj Camp that has proved inadequate before. The other is a new one at Rajuk Apartment Project near Diyabari in Uttara.

In the medical arena, there has been progress as well. Isolation wards to treat COVID-19 patients have been set up in district-level hospitals across the country. Students and teachers of the Faculty of Pharmacy at the University of Dhaka have started making low-cost hand sanitizers due to market shortages in the wake of coronavirus fears. And, Gonoshasthaya Kendra, a public health center in Dhaka, received approval from the country's Directorate of Drug Administration (DGDA) to mass-produce COVID-19 detection kits, each costing around $3.

Recommendations for tackling the situation

Policymakers in Bangladesh should gear up in anticipation of a deterioration of the situation. While the Asian Development Bank (ADB) has promised a $6.5 billion package to address the immediate needs of developing member countries (DMCs), and India's Prime Minister Narendra Modi has pledged $10 million toward a special emergency fund to set up a rapid response team for the South Asian Association for Regional Cooperation (SAARC), Bangladesh will have to face this battle largely on its own. Over the past ten days, the South Asia Center has consulted broadly with public health professionals and social scientists who study Bangladesh. Those conversations lead us to offer the following healthcare, social, and economic recommendations:

Health Care

Support initiatives to increase the local production of medical gloves, masks, and other medical kits for health care practitioners who, as the front line defenders, are the most vulnerable. According to Health and Family Welfare Minister Zahid Maleque, as of now, Bangladesh has adequate testing kits and personal protective equipment (PPE), numbering around two hundred thousand units. On March 26, a large consignment of emergency medical supplies provided by the Chinese government arrived. This shipment included 10,000 testing reagents, 15,000 surgical masks, 10,000 medical protective equipment, and 1,000 infrared thermometers. But, as the grim lessons from other countries make clear, in the case of a mass outbreak, even more PPE will be required and more testing needs to be done.

COVID-19 testing facilities should be made available across both public and private medical centers with immediate effect. Once locally produced full-scale standardized and accurate kits are available, testing capabilities should be distributed to other locations in Dhaka and across the country. Bangladesh should commit to mass testing on about one percent of its population to identify community spread of COVID-19. As of March 29, Bangladesh's official COVID-19 tracker confirms forty-eight cases and five deaths. A press conference that day stated that 1,185 tests have been conducted thus far. This number is much lower in comparison to India and Pakistan, who as of March 29, have tested 27,688 and 14,336 cases respectively.

Implement awareness campaigns for the general public. Unless an individual is over sixty-five and/or has pre-existing health conditions, symptoms should be followed by a six to seven-day quarantine period and individuals should not go to health care facilities. If an individual's health condition continues to deteriorate, they should then go for COVID-19 testing.

Emotional and mental health services, as well as financial support, should be provided for health workers. The medical community of the nation at this point are severely at high risk and are fearful.

Social

The Ministry of Religious Affairs should endorse the fatwa of the Council of Senior Scholars at Al-Azhar, one of the Muslim world's top Islamic institutions, where it is permitted under Sharia Law to suspend congregational prayers to counter the spread of the virus. Many Muslim-majority countries in the Middle East including Saudi Arabia have banned gatherings such as in the holy cities of Mecca and Medina.

Restaurants and public locations should remain closed after April 4 for a period of at least another ten days, and citizens should be prepared for even longer disruptions of daily life. There must be tougher self-quarantine norms-and if needed lockdown measures-in certain areas of the country with higher concentrations of Bangladeshi expatriates. Sri Lanka had instituted a stay-at-home curfew in eight districts of the country, where violation of this measure has led to the arrest of over 1,600 people. Now that the army has been summoned in Bangladesh, certain districts across the country can be asked to impose curfew-like restrictions, with violations leading to strict punishment and fines.

The government must utilize television, radio, and social media to counter the spread of fraudulent treatment methods through disinformation channels, and to raise appropriate awareness of COVID-19's dangers for even otherwise healthy victims.

Village community leaders such as Imams and village elders should be involved in spreading information on countering COVID-19. Local non-governmental organizations (NGOs) and government officials have a list of such leaders and can centrally coordinate their response.

Private universities should be mobilized to provide premises for quarantine facilities and temporary hospitals, given that many of them have campuses located right outside Dhaka. Similar initiatives have been taken by higher educational institutions in the United States.

Economic

In concurrence with the Centre for Policy Dialogue (CPD), one of Bangladesh's leading economic think tanks, leniency should be provided for loans to small and medium sized-businesses and extended pay back periods granted. Prime Minister Sheikh Hasina announced a stimulus package of Tk 5,000 crore ($590 million) for the export-oriented industries. However, it is also imperative that the government provide smaller entrepreneurs with fiscal support so that they can maintain production and pay workers' wages.

To protect daily wage laborers who have not left Dhaka to return to their hometowns, tougher lockdown measures accompanied by supportive humanitarian measures should be implemented in slum areas where daily wage workers are concentrated. As in the Rohingya camps, daily wage laborers should be provided with rations for two weeks so that they can observe social distancing measures without risk of starvation or malnutrition. Such a policy could build on the precedent by the neighboring Indian state of West Bengal, which will provide free rations to the poor until September. Additionally, as the month of Ramadan is approaching, zakat funds should be collected by both the government and NGOs for this purpose

The government must provide the necessary financing to allow Gonoshasthaya Kendra and other health care organizations to produce their COVID-19 testing kits at requisite volumes and support distributional channels to allow medical facilities around the country to access these kits.

The government must help catalyze the funding required to enable the local production of hand sanitizers and PPEs, which are being made by university students and small tech companies. This will disincentivize counterfeiting and fraud.

Over the next six months, the government must ensure that strategies suggested by the ADB and other international organizations are implemented without delay to minimize the inevitable economic slowdown that will follow even a successful fight against the novel coronavirus.

The global COVID-19 pandemic is caused by a once-in-a-generation pathogen that has proven capable of bringing the health systems of the richest countries of the world to their knees. The damage that will be wrought on developing country populations if their governments delay implementation of aggressive countermeasures is unimaginable. Living in densely populated areas with large sections of society reliant on daily wages to make ends meet-and served by public health systems that have been deprived of investment for decades-Bangladeshi citizens are among the world's most vulnerable to the unchecked spread of this disease. But the situation is not hopeless, and Dhaka must utilize every tool in its arsenal to serve its citizens. The policy checklist presented above is a good place to start.

From the Atlantic Council.

Dr Irfan Nooruddin, Ph.D., is the director of the South Asia Center at the Atlantic Council and professor in the School of Foreign Service at Georgetown University.

Dr Rudabeh Shahid, Ph.D., is a nonresident senior fellow of the South Asia Center at the Atlantic Council and a postdoctoral research fellow at the University of York.