Prime Minister Narendra Modi while addressing the nation on Friday, 20th March 2020 urged Indians to face the COVID-19 pandemic with collective determination and patience. He also called for a “Janta Curfew”, a voluntary 14-hour lockdown on 22nd March 2020 from 7 am to 9 pm: by the public, for the public.
Though largely symbolic from a public health perspective (do not trust the social media forwards which tell you such a small period can help vanquish the virus), this serves as a useful drill. This will give Indians an insight into what it would mean to go in for an extended potential future lockdown. Some states like Odisha, Rajasthan, and Punjab have already announced lockdowns of varying geographical coverage for a week or longer. As of 22nd March 2020 afternoon, lockdown with only essential services operational was further announced for 75 districts.
This list will probably grow over the next couple of days. This has led several to ask a question: what is the use of a lockdown and how long should it go on for: a day, a week, two weeks, or even longer?
These lockdowns are the latest in an expanding COVID-19 government response which included travel restrictions, issuing protocols, guidelines, and advisories, providing testing, establishing isolation and quarantine centers and setting aside hospital and ICU beds. While the initiative is commendable, there have been concerns around decisional delays and a lack of clear communication and transparency.
We have had a proliferation of usage of terms, often inter-changeably: social distancing, mass gatherings, lockdowns, shutdowns, curfew, prohibition, stay at home, shelter-in-place, home isolation, quarantine to denote some or all the actions. This has ended up confusing people; added to this is misunderstanding even among government officials with regards to the use of ‘Local transmission’ to denote Stage 2 and ‘Community transmission’ for Stage 3.
The main and only difference between Stage 2 and 3 is the ‘Known’ vs ‘Unknown’ chain of transmission. This is a crucial difference that will dictate the response strategy. In Stage 2, incoming infected travellers are spreading the infection further at home, workplace, or in social settings i.e. among known contacts, and a chain of transmission through contact tracing can be established. Therefore in ‘Local Transmission’ all chains of transmission are known, accounted for and under observation. Only when a new case is discovered which cannot be connected to a known traveller or their contacts, can we say ‘Community Transmission’ is happening (Stage 3). This is an unknown transmission because we do not know from whom the infected individual acquired COVID-1
Due to stringent ICMR testing guidelines till March 20th, which many found irrational, only a person who was an incoming foreign traveler with symptoms OR a contact of a confirmed positive individual OR a small group of individuals from the community with specific respiratory symptoms were tested for COVID-19. This probably gave us a false sense of security, only broken when the reports from Tamil Nadu, Pune, and Delhi about potential community transmission came through. Reassuringly, the ICMR has now relaxed the testing eligibility also allowing for symptomatic health care workers, and all hospitalized patients with Severe Acute Respiratory Illness (SARI) to be tested.
When this article was written, the official stand of the Government was that India still does not have any Community (unknown) transmission. However, as described earlier, many states and cities have initiated ‘lockdowns’ of varying degrees (with respect to mass gatherings, closed schools, pubs, theaters and function halls) for different durations as if we are already in Stage 3.
The steady increase in the number of positive cases in multiple states since March 3rd after a lull in February in combination with the rapid global spread especially in Europe, Iran, and the US has probably created fear among (especially state level) policymakers, and the public, that unknown transmissions are happening in India and cases will continue to climb, and it’s politically expedient to act. The Union government has neither itself or through directives to states required that stringent measures should not be taken unnecessarily, without a clear rationale outlined and communicated to the public.
For example, Odisha with only 2 cases reported, has announced putting 40% of the state under lockdown. Rajasthan and Punjab soon followed. These actions appear to be ad-hoc knee jerk reactions rather than a well thought out strategy. We should avoid a lockdown competition among Chief Ministers and following the herd mentality (because Italy, France Spain, US, UK, and others are doing it).
While preserving the health of populations is crucial, it’s important to remember that lockdowns have severe economic and social impacts. The ensuing economic disruption could spell disaster for many small businesses, travel and hospitality industry, daily wage earners and other economically vulnerable groups unless compensatory support is provided.
As such, these measures must be judiciously exercised based on real-time local data. It should balance public health goals with economic and social stability. The most appalling lapse on the part of the response has been its failure to clearly define the current goal- is it containment or mitigation?
If we can find and break all known chains of transmission, then containment must be the goal i.e. to isolate suspects, test, treat infected individuals and trace contacts to suppress the virus transmission. But if there are multiple unmanageable unknown chains of transmission in the community, then mitigation becomes the goal.
Though the goals are different, there is a huge practical difference. Under mitigation, contact tracing is deemphasized and lockdowns are initiated (see graphic). All other actions like personal hygiene (wash hands, cover cough etc.) should be practiced for both the goals (another thing not communicated properly). Currently, Singapore, Hong Kong, South Korea, and Taiwan are attempting containment; Italy, France, Spain UK and some parts of the US are attempting mitigation.
Under mitigation, we accept that the virus will spread in the community and we can only slow it down and not stop it. By slowing it down, we reduce the pressure on the health care system (flatten the curve). When a lockdown is implemented, we are trying to reduce the interactions and exposures between strangers to slow the transmission- we are indirectly saying everyone is a COVID-19 suspect and we need to maintain distance from them all. This purpose might be defeated if it is not done in an orderly manner due to confusion and panic.
It will be counterproductive if people do compensatory rebound interactions before or after lockdown (panic buying and hoarding in congested supermarkets) which increases exposure.
Lockdown is not an absolute panacea for COVID-19 spread. It should not be applied out of context and cannot be maintained indefinitely. Though the measure is extreme, it only results in postponing the eventual spread. It should be part of a coordinated, coherent and sustainable COVID-19 response strategy.
Given the economic and social consequences, this arsenal should be used tactically as a last resort in localized hot-spots of infection identified through quality surveillance to achieve a clearly defined objective (reduce new cases/hospital admissions or to do active case finding by the door to door survey).
The government should come up with clear guidelines for lockdown which is categorized and proportionate to the perceived risk based on real-time local data and health system capacity. In a democracy like India, we should adapt our own strategy on the extent of lockdown and have a graduated system of restrictions after taking the public into confidence. These guidelines should be publicly communicated, and answer at a minimum the following:
Why: The reason and immediate objective behind the lockdown.
When: The trigger for the lockdown based on near real-time local data considering lags. Is it a steep increase in daily new cases for the past three days or concerns around stretched health system capacity or out of an abundance of caution?
Where: The geographic areas and administrative borders that are going to be included in the lockdown
What: The level of lockdown. Is it minimal, moderate or at maximum? What businesses can be operational in what manner under each of these levels? What actions are permitted and not permitted?
Who: Who/how many can come out, at what times and how frequently? Who should report regularly for work at each activation level?
How: This consists of two parts- How long the lockdown (depending on the objective) for --this should be based on scientific evidence and public health advice; also how will it be carried out— how will we avoid panic? How will sick people during the lockdown seek care? How will food be delivered to households which can’t buy and store? How would old people in secluded homes be taken care of? How will people in transit or at borders be advised? How will homeless, beggars and daily wage earners or small shop owners like tea stalls be compensated? How will we monitor the lockdown? Will we police the lockdown, and fine/take legal action against those who violate it, even for legitimate reasons (such as a family emergency)?
Lockdown might be thought of being akin to a nuclear strike option on a viral spread, but it is unchartered territory in this regard for us as we have never used this strategy in India. Furthermore, it can at the most buy us precious time. It might serve us better to be innovative, evolve contextually relevant models of lockdowns and redefine how these can be humanely implemented. We should not go into mass lockdown at the first sign of unknown (community) transmission.
We should try to contain COVID-19 transmission with maximum effort as this will have the least economic and social impact. We should do extensive testing, recruit volunteer contact tracers and use India’s technological strengths for ethical surveillance tool development to achieve this. When all chains of transmission are seemingly known, even with a few exceptions, we should follow the adage “Don’t use an axe to cut a nail”.
But when there are unmanageable unknown transmissions happening in the community, ”Never bring a knife to a gunfight” should be the guiding principle and the state should exercise full measures at its disposal, including extended lockdowns to save lives.
We need the Government to come up with transparent and evidence-based criteria and guidelines for its own approaches and policy actions, including lockdowns, to enable confidence in its COVID-19 response and enable adherent participation of the public.
Dr Manjunath Shankar is a public health specialist. He participated in the US CDC Emergency Response (Modelling Task Force) to the West African Ebola outbreak in 2014-15.
Dr Anant Bhan is a researcher in global health, bioethics and health policy.