Is a country-wide lockdown a feasible strategy to contain COVID-19 in India?

[dropcap]T[/dropcap]HESE are critical times for the entire world. COVID 19 (Corona Virus Disease) which supposedly originated in an animal market in Wuhan, China, has spread across the globe and has been classified as a 'pandemic'. As per World Health Organisation (WHO) data, released on the March 26 2020 (18:00 CET), 199 countries, areas and territories had confirmed cases of individuals infected with SARS CoV 2 (SARS Corona Virus 2).

Though the term 'pandemic' is widely perceived as characterizing something alarming –  it only means the spread of a disease across international borders. It is not related to the severity of the disease.

What do the data say?

The virus is highly contagious i.e. it spreads very fast and infects people in a short period of time. However, the current case fatality rates vary from 1 – 11 % across the countries. Out of the total population infected with the virus, approximately 80% are likely to remain asymptomatic (without any symptoms) or show mild symptoms; 14-15% are likely to experience severe symptoms and may require hospitalization and 4 – 5% will be critically ill and will require intensive care treatment including respiratory assistance with ventilators.

The current data also shows that the clinical severity is disproportionately higher in vulnerable population which includes older people, people with chronic diseases including kidney, liver and heart diseases, poorly managed diabetes, terminally ill patients, chronic smokers etc.

Out of the total COVID-19 mortality in Italy, 40 % of people who died due to the COVID-19 infection had no other co-morbidity conditions. The rest of 60 % mortality is due to other significant diseases which increased the severity of COVID-19 and contributed to the mortalities.

Measures to control transmission

Young people are mostly carriers of the infection, transmitting it to the vulnerable people who face the negative consequences of the disease. Hence, it is important to follow the preventive measures including social distancing, hand hygiene and quarantine and isolation practices to prevent the transmission of infection to vulnerable individuals.

The government of India has taken various measures to stop the transmission of the infection and prevent mortality due to a spike in cases; which might overwhelm the healthcare system. This includes a sudden lockdown of the entire country and sealing of international borders to prevent the arrival of infected cases from other countries and restrict the free movement of infected individuals in the country to prevent the spread of infection.

Is lockdown an effective solution?

The lockdown is an important strategy to prevent a sudden rise in infected cases and mortalities. While it will help flatten the pandemic curve in the country, it will be effective only if combined with intensive testing of the population, isolation and treatment of those who test positive, and rigorous tracing and quarantine of the contacts.

Testing in the country is far below the required level and there is not much evidence which proves that viral epidemics or pandemics can be stopped through lockdown only. Spain and France are currently witnessing the surge of cases despite an early lockdown.

There are also chances that despite the lockdown the virus is circulating in the community (low transmission) but it may spread again widely and lead to a surge of infections once the lockdown is waived off.

Technically, if applied as a strategy, multiple sequential lockdowns are more effective to prevent the cases. However, we as a country cannot afford a series of lockdowns. As a matter of fact, we cannot afford even a single countrywide lockdown.

If the strategy of the government of India behind a single lockdown is to buy time to improve health systems to handle a sudden rise of cases after the lockdown period, then the government needs to exponentially ramp up efforts to strengthen our health system to be prepared to handle the sudden rise in cases in the few weeks after the lockdown. This includes ensuring proper testing and treatment services, procurement of personal protective equipment for healthcare workers and community health workers, scale-up of intensive care units and proper distribution of workforce among other things.

Also, if the strategy behind the lockdown is to buy time to reach the summers – like rising in temperature has been shown to reduce the transmission of many flu viruses – then it is not proven that high summer temperatures will stop the transmission of SARS CoV 2. It is possible that the virus may continue to be transmitted at lower rates and that there will be a second surge in monsoon or winters. The great Spanish flu of 1918 had a similar pattern.

Considering the density of population living in slums, crowded mohallas and societies, prisons, brothels, the measures of social distancing are impractical. Those who are living in these places are already more vulnerable to significant transmission if the virus is already in circulation in the community.

What price India may pay for this lockdown?

Every day around 1,200 tuberculosis patients dies in India, despite undergoing treatment. Around 2,000 infants and 800 mothers die per day in our country due to preventable causes. The deaths due to heart attacks, diabetes complications and other lung and kidney diseases are also very high in India. These patients living with chronic diseases are dependent on continuous healthcare services. Due to the lockdown and an intensive approach to curbing this pandemic, these services will be hugely compromised. This will lead to an increase in mortality and morbidity. This will continue not only during the period of lockdown but also in the upcoming weeks and months.

The entire system of vaccination and maternal & child health services will also collapse during this lockdown which will affect the health of millions in our country in the upcoming months.

The mental health of millions of people, the most ignored aspect of public health, has already been compromised due to fear, panic and isolation during this lockdown. This will significantly lead to a rise in cases of depression, anxiety, domestic violence and even suicides which will have long-lasting impacts.

India is home to a quarter of the world's hungry people. 194.4 million in India are undernourished. Around 21.1% of the total population is living below the poverty line. This lockdown will lead to widespread hunger in these marginalized groups leading to a high number of malnutrition and hunger-related deaths. Despite the relief package announced by the government, food is beyond the reach of many.

The situation may lead to breakdown, violence and civil unrest. Millions of daily wage workers, slum dwellers and artisans will receive a severe blow economically. This lockdown will destroy livelihoods of many which will have long-lasting consequences leading to widespread hunger, malnutrition, deaths, suicides and increase in crime rates in the months to come.

India's economy is already experiencing a downturn. The consequences of the lockdown on the economy and healthcare systems will be disastrous. The situation has started deteriorating as thousands of migrant workers have started the journey to their hometowns on foot; covering hundreds of kilometres, walking under the bright sun without food, drinking water and place to rest. The widespread hunger and civil unrest, in the long run, will further increase the mortality rate in the coming months.

There are strategies that could have been employed instead of locking down the entire country. We do not have the luxury to impose a countrywide lockdown on the lines of some developed countries. In fact, the western world is also collapsing due to this lockdown. The countries like South Korea, Singapore, Japan have managed the pandemic without imposing these draconian measures. Many countries, for example, Indonesia that cannot afford lockdown, are using other strategies to respond to the threats imposed by COVID-19.

The vaccines and proper treatment for the disease are nowhere in sight and we just cannot sustain this lockdown for that long. There are few questions which arise here, namely:

1. Are we ready to reduce COVID-19 mortalities at the cost of deaths due to hunger, malnutrition, other chronic diseases – which could be multiple times than COVID-19 mortalities?
2. Are we sure that the lockdown is going to work without combining it with other effective public health strategies?
3. Are we ready to weaken our economy and healthcare systems to respond to this epidemic?
4. Can't we choose alternative effective strategies to save lives without overwhelming the healthcare system?
5. Are we ready to bear months and years of hardships by adopting a strategy that has equal odds of not being successful in our country?

There is a natural cycle of every epidemic/pandemic which occurs in the form of a bell-shaped curve. The efforts are made to reduce the peak of the pandemic to reduce morbidity and mortality.

We have put a lot at stakes by imposing these strict measures. However, as responsible citizens, we should maintain social distancing and practice all the measures to prevent this transmission and reduce the number of cases.

Note: The views and opinions are personal. As the science of COVID-19 is dynamic, the facts and figures are changing, this article is based on the knowledge available as on March 27, 2020. The article is submitted on March 28, 2020.

[Dr Abhishek Royal is a medical doctor and a public health professional with experience of working in public health emergencies in India. He is currently pursuing Master's in Public Health in Implementation Research from Universitas Gadjah Mada, Indonesia as a World Health Organisation – Special Programme for Research and Training in Tropical Diseases scholar].