This is an edited version of an op-ed for a newspaper that did not see the light of day. Some of the ideas expressed may be dated given the rapidly evolving nature of COVID-19, but the op-ed was addressing the nationally applied lockdown situation prevalent then. The central “dogma” though of moving action from a central State to communities applies across national, urban, district and other settings. Updated with links to other talks and stories as well.
“And from making the cure of the disease more grievous than the endurance of the same, Good Lord, deliver us”.Sir Robert Hutchison
Thus begins a textbook of medicine by Robert Hutchison that many doctors (at least in the British Commonwealth thanks to our colonial baggage) have studied. A very timely quotation for the times we find ourselves in, amidst a prolonged lockdown in response to COVID-19. There is no better time than this to critically examine the benefits of a blanket nationwide lockdown, given what we know of the natural history of epidemics at a population level (as opposed to individuals). While the reliance on doctors and clinical specialists for what to do next is well-placed to inform us on preparedness in hospitals, we ought to rely on the body of knowledge in epidemiology and public health on preparedness and what to do next in populations and societies.
The last few weeks have been overwhelming and unprecedented. It appears as if there exists a remote control device for a nation and at a crucial time, a pause button has been pressed so that we can shelter from the (COVID-19) storm. Epidemiologists and public health experts tell us that our response has been strong enough and has arguably changed the shape of the disease curve, even if it has not flattened it yet. However, can we remain in nationwide lockdown and wait for this storm to pass? What if it takes a month or a few more months? What lessons have we learned from previous epidemics that could inform our decision-making? In this article, I provide an overview of public health approaches that are likely to help us move towards exiting a nationwide lockdown. Indeed, the ill-effects of the lockdown itself have been inequitably shared by different sections of the society while on the other hand, the COVID-19 positive cases continue to grow day-by-day. Based on population health principles, there appear to be sufficient grounds to move towards a graded lockdown implemented in a localised manner, shifting mitigation strategies to local governments and implementing a syndromic approach to flu-like illnesses even as we expand access to testing.
Moving away from big-bang control to community-based control
The lockdown imposed by the Indian Government, and the efforts by the Indian Council of Medical Research (ICMR), and the health ministry to effectively monitor the disease have been crucial in possibly changing the course of the epidemic. However, results from the monitoring of 41 influenza-like illnesses surveillance sites across the country by ICMR published in the Indian Journal of Medical Research confirm what many Indian microbiologists and clinician-scientists had predicted: that the disease transmission cannot be contained and that there is indeed widespread community transmission. Given this scenario, remaining in lockdown, however strictly and well-implemented, while important, is insufficient if it is not accompanied by a decentralised and community-based response.
It is not surprising that highly transmissible influenza viruses such as COVID-19 cannot be contained despite days to weeks of nationwide lockdown. Even if we were to have a universally and extremely well-implemented lockdown (the so-called perfect response), where everyone behaves as instructed, such a highly transmissible viral illness cannot be contained and eradicated. Even as we close ourselves behind the high-walls of lockdowns, a minuscule slip here and there are sufficient to keep the transmission alive. Given this scenario, is it advisable to continue to be under the lockdown blanket, hoping that the passing monster will leave? Overwhelming public health, epidemiology and virology experience tells us that such lockdowns and safety blankets are temporary measures that are useful only if accompanied by widespread investments in strengthening our health system response on one hand and an inter-sectoral, inter-departmental and a decentralised response on the other. Recent pronouncements from WHO’s chief scientist, Dr. Soumya Swaminathan and statements from Indian associations of community medicine and public health also echo this.
We need a graded response, ranging from total and complete lockdown to near-normal areas based on a more fine-scale understanding of transmission hotspots, while relieving other locations with relatively limited transmission. This requires disease surveillance capacity at district and sub-district level and a decentralisation of decision-making from union and state government to district collectors, taluka administration and local governments. More localised and decentralised lockdowns are also likely to be better adapted to addressing the inequitable effects on the poor and disadvantaged who are bearing unfairly higher burden of the blanket nationwide lockdown.
Leveraging primary health care
One of the advantages that India has when compared to many other countries in the news for high mortality is our decades-long investment in a nationwide network of primary health centres (PHC). These are the building blocks of the Indian health system, and our strength is that we have a cadre of community health workers (the ASHAs, one in almost every village) and a PHC for every 15-20 villages. Even though the last few years have seen a diminished focus on strengthening our PHCs, they still remain the powerhouses for disease surveillance, preventive care and health promotion in addition to catering to the poorest and socially disadvantaged sections of our society. We must urgently invest in building capacity of our PHC doctors and frontline health workers to raise awareness and implement mitigation strategies (physical distancing, averting stigma, raising awareness on hand and respiratory hygiene), while carefully ensuring that inadequately protected health workers themselves do not inadvertently transmit infections as well as take on risk. In fact, essential health services such as immunisation and care for chronic conditions (such as Diabetes, Epilepsy, mental health problems etc) are suffering due to near-complete monopolisation of our scarce health workforce in COVID-19 response.
Syndromic approach along with testing
One of the big criticisms about the Indian response has been the insufficient expansion of our testing capacity. While this can and should be critically analysed both from scientific and operational angles, now is the time to deploy time-tested population health responses in times of pandemic, the so-called syndromic approach. At the heart of this approach is to respond to any individual conforming to a given set of signs and symptoms as if they are likely to be positive for COVID-19. The syndromic approach allows us to move towards localisation and containment rapidly, allowing the testing expansions to catch up. This also allows us to carefully monitor and follow up the high-risk individuals among those who are positive in the syndromic approach for development of severe acute respiratory illness. Timely referral to an appropriate facility for those who develop SARI is vital in keeping mortality low, while on the other hand relieving higher level hospitals from widespread hospital-quarantines. A decentralised community-based isolation for non-serious and mild symptomatics (which is a large proportion of those infected with COVID-19) is the direction in which we need to move in the coming weeks to months. As our experience with flu epidemics tells us, eventually most of us will be infected and indeed most of us will recover.
Social media is rife with instances of violations of basic principles of a lockdown such as physical distancing. This has either led to demands for greater and stronger policing or elsewhere panic-stricken requests by citizens for extending lockdown. We must realise that the lockdown is a means, not the end for combating COVID-10. We cannot keep the pause button pressed till one fine day there is no more COVID-19 among us. Instead, we must use the lockdown period to shore up our healthcare systems. On the other hand, this is also a time to communitise our response; we must take as many of our fellow citizens into confidence in an inclusive and empathetic manner. This requires leadership on multiple fronts, not only from politicians and public health professionals but also by communities. And we must achieve this by putting our best foot forward and not by imagining that the lockdown will protect us fully. The last few weeks has already sensitised us on the need for various mitigation measures across the country. We must aim now for supporting our local governments, panchayats, taluka and sub-district level administration, even if the response is far from perfect.
In summary, COVID-19 is likely to infect a lot of us; that is inevitable. In fact a large proportion of those infected will shake it off in a few days or not feel anything at al. The key question is how prepared are we to avert preventable mortalities and hospitalisation that is required for a small proportion of those infected. The only way to do this is to be prepared and strengthen our ability to limit spread through decentralised and focused lockdowns in some places. Much like the early treatment for cancers harmed healthy cells as much if not more than the cancerous ones, prolonged nationwide lockdowns run the risk of harming the entire population all at once. As we move towards exiting lockdown, we must rely on more decentralised decision-making and mitigation strategies.