Tackling Coronavirus: Ensure A Balanced Policy, With People's Participation
Will the lockdown be lifted or won’t it? A former health secretary sets the agenda for the coming days
More than ever now is the time to battle the coronavirus with evidence to guide strategy. It is time to look into past experience to help arrive at a balanced policy for a post national lockdown from 14 April.
India has a rich experience in fighting viruses: smallpox, polio, HIV and H1N1, SARS, ZIKA, etc. The most recent was H1N1 that disproportionately affected persons below 60 years, as opposed to COVID-19 that attacks the elderly more and is highly contagious. Within the period August 2009-10, H1N1 accounted for over 44,000 cases and 3,800 deaths. The coronavirus seems to be following a similar trajectory but is expected to be more virulent.
Though the HIV was not a super-spreader like the coronavirus, yet the principles used for its containment were similar–testing, tracing, treatment and behaviour change by use of condoms. Again, like the coronavirus, HIV could also be active without showing symptoms.
Lessons from the HIV Experience
As HIV spread only through sexual contact, those with a history of risky behaviour were traced out and tested. To ensure keeping an eye out for spreading into the general population, random sampling of antenatal women was also undertaken. As expected, data showed huge differentials between high-risk sub population groups like sex workers and others. Husbands of infected women were tested, source of infection traced and hot spots identified. Besides, snowballing techniques were also implemented and trace maps of infection transmitters prepared.
Zeroing on these hot spots then enabled vigorously implementing strategies to disrupt the transmission. Since the condom was our only prophylaxis, wide access to information and its availability gained precedence until unprotected sexual activity became the norm. HIV-infected persons were provided testing and counselling services in addition to treatment. Thus, the strategy was comprehensive—combining prevention and medical components around the central ideas of testing, tracing, and treating. Incidence of HIV dropped by 67 per cent with the implementation of these strategies, making it the highest in the world.
Compared to HIV or H1N1, tackling the corona epidemic is manifold more complex due to three factors. One, its highly contagious nature evidenced by the speed with which it has spread among geographies and populations within an incredibly short time frame. Two, mode of transmission–through droplets as well as the touching of contaminated surfaces, necessitating physical distancing and frequent hand washing. And three, absence of any effective treatment protocols or vaccines, increasing fatality rates. While the HIV has no vaccine, it has effective drugs that can keep an infected person alive and healthy for several years, while a H1N1 patient has both effective treatment and vaccine.
As the coronavirus has resulted in unprecedented levels of caseloads and case fatality, nation-states have resorted to extreme measures like locking down of all physical movement except for essential needs. These measures, however, entail massive social and economic costs. In India the 21-day nationwide lockdown is expected to end on 14 April. On every ones’ mind is whether the lockdown will continue or not.
The decision on the future policy will depend on the behaviour of the virus. Testing has, after a miserable start, gained momentum. Increased testing has thrown up an increased number of caseloads. Testing is the only means of measuring its trajectory. However, there is little data put in the public domain, making it difficult to analyze and assess the severity of the epidemic in India. What is known is the number of positives. What is not known is information regarding the state-wise number, location and demographies of the tests conducted on each day. In other words, if 100 tests were carried out in Delhi on a particular day in one area of the city, the resultant positives will only be from that area and cannot be extrapolated to represent the status of the whole city.
Several states are asking for prolonging the lockdown—Odisha has been the first to announce it—though on what evidence or basis is unclear. At the same time, the lifting of the lockdown and allowing free movement could also have attendant risks that can be difficult to manage later. It is easy to impose lockdowns but the costs are borne disproportionately heavily by the poor, worsened by the near absence of social security. In view of these factors, it appears to be reasonable to expect a graded lifting of the lockdown by categorizing the districts into not affected, mildly affected and severely affected. Insulating some critical industries vital for the running of our economy may also be needed.
Whatever the decision, it must be based on evidence and science and fully placed in the public domain. One of the non-negotiable principles of public health is effective communication for ensuring people’s participation. Every option has trade-offs. It is important for the political leadership to not just take a balanced view but also obtain social consent for optimizing its outcomes.