By Chandrakant Lahariya
When Wuhan in China came out of the lockdown after 76 days, the COVID-19 situation was largely under control. India had a slightly shorter but a more stringent nation-wide lockdown in four phases, yet the situation at the end of lockdown in India is very different from Wuhan. Six weeks after opening up, the number of new cases is increasing nearly every day. Though nearly 80 per cent of the cases have been reported from 49 districts and nearly half of the total cases are from 10 cities, more cities are reporting an increasing number of cases. Against this backdrop, a number of states and districts in India have attempted varied versions of the lockdown – these include day long, weekend and extended weekend lockdowns as well as various forms of night, day or hourly curfews.
The initial lockdowns were with the specific purpose of reducing the rate of transmission and getting health systems (both public health and hospital services) ready for a surge in cases. The four lockdowns till May 31 have largely served the purpose. There is increased testing capacity, better provision of isolation, oxygen and ICU beds and ventilators. The public health and social measures such as wearing masks, hand-washing and social distancing are being better enforced. Public communication has focused on reducing stigma and discrimination and the health workforce is better equipped with PPEs.
Such additional objectives are missing from the newer versions of the lockdowns and curfews. Experts have raised the question: How many more lockdowns are needed to get our health systems ready. Or, if the purpose is reducing the rate of transmission, then are enough complementary public health measures being implemented? The “chasing the virus” approach in Dharavi, Mumbai and the repeatedly underlined approach of “test, trace and treat” strategies, implemented with renewed attention in Delhi after mid-June, are proof that a lockdown is at best a facilitating tool and its overuse may not be helpful. After all, in many parts of the country, people have lived through a lockdown for 100 or more days. Therefore, a few days ago, when the chief minister of an Indian state did not see any merit in extending the lockdown, he had a point.
Clearly, if lockdowns were to prepare the system, it has been more than four months since the first lockdown was imposed. If this period was not enough to prepare the system, what more can be achieved in a lockdown of another one, two or even three weeks?
With the newly developed understanding that COVID-19 is here to stay for months and no vaccine is likely to be available for wider use before the middle of next year, the strategies to respond to the pandemic need to be based upon a nuanced understanding of epidemiology, effective implementation of public health and social measures and improved community engagement. Easy as they may sound, they present challenges when it comes to implementation in non-metropolitan cities, which are reporting more cases today. However, these approaches need to be followed for an effective response to the pandemic.
A nuanced understanding of epidemiology requires use of figures beyond recovery rate and doubling rate. From the very beginning, these two rates have guided our response to the pandemic; however, these are not useful as they were earlier. For example, there is no benchmark for the recovery rate. At the end of the pandemic, it will be close to 99 per cent. Moreover, as cumulative cases have been reported over a period of four months, even a surge in new cases will not be fully reflected in the recovery rate. Therefore, if the purpose is to send a motivational message to people, the recovery rate is a good indicator. However, a pandemic cannot be fought on motivation only.
Similarly, the doubling rate at 20,000 cases is more likely to be longer than at 10, 50 or 100 cases. While these and many others have been effectively used, the current stage of pandemic requires capacity and expertise at every district of India to analyse, interpret and provide independent expert advice to help district authorities calibrate public health measures. Community medicine departments of medical colleges and epidemiologists from various institutes should be actively engaged in this process.
The pandemic is already shifting to tier II & III towns which lack the capacity for public health measures of “trace, test and treat”. These towns need to be immediately supported. The focus should be to increase testing to reach around 1,000 test per million people per week for all settings. The test positivity rate should be aimed at below 5 per cent. Clearly, there are well laid down criteria, which need to be used for an effective pandemic response. Well-designed risk communication needs to ensure that stigma and discrimination do not come in the way of seeking early testing and care. The experiences of people who were ultimately found to be COVID-19 positive needs to be understood to ensure that there are no barriers in seeking care. Hospital beds should always be at hand for the 15-20 per cent patients who would need hospitalisation. However, nearly 80-85 per cent patients would require initial contact with the health system and this demands the revival and strengthening of primary healthcare and community outreach health services for COVID, as well as other ailments.
Africa’s experience of Ebola has shown that communities have a vital role to play in the pandemic response. Public health and social safety measures such as use of face mask, hand sanitisation and social distancing are going to be vital in the long-term fight against the pandemic. However, a coercive approach is less likely to succeed and participation of influential community members, resident welfare associations in urban areas and elected representatives including members of panchayati raj institutions would be essential to sustain these interventions.
The response to COVID areas other than state capitals and metropolitan cities seems to be based upon the two pillars of lockdown and hospital readiness. At the first hint of a surge in cases, the local authorities seem to resort to a lockdown which may slow down the spread but may not solve the problem. It is time that district level capacity and expertise in epidemiology is strengthened, more attention is given to ensure that the public health and social safety measures are adhered to and communities are involved as important stakeholders in the entire process. That will reduce the need for any further lockdowns.
The writer is an epidemiologist and public health specialist. Views are personal