Lockdown lessons: A one-size-fits-all approach should be avoided in a country as vast as India

As India endures a fifth consecutive week of a nationwide lockdown – ranked as the most stringent in the world by the University of Oxford – to contain the spread of Covid-19, it seems an opportune moment to reflect on its rationale, its impact, and where we need to head from here.

The singular goal of the lockdown was to save lives – both, by protecting every individual in the population from being infected, and by slowing the surge of cases which might overwhelm scarce intensive care resources. This is a moral goal that no one can argue with. Two questions spring to mind in relation to this goal: Will the lockdown lead to reduced numbers of lives lost due to Covid-19, and will a policy focussed on saving lives from one disease inadvertently lead to more deaths by other causes?

Covid-19 deaths

Let us consider the impact of the lockdown strategy on mortality due to Covid-19.

Contrary to what one might have expected, the number of deaths due to Covid-19 has actually been increasing with each week of the lockdown. This suggests that there was a much wider spread of the infection before the lockdown and a limited impact of the containment policies in those crucial weeks.

Still, there is no doubt that the longer the lockdown is in place, the curve of infections will ultimately flatten and then fall. After all, if everyone is forced to stay at home, there is no way for the virus to jump from one person to another – except, of course, between those in the same house. Such a lockdown would have an impact on all contagious diseases.

But it is a fundamental mistake to think that the coronavirus would then have been eliminated. Only a vaccine or the acquisition of “herd immunity” – when a specific proportion of the community has been exposed to the infection due to its gradual spread in the population – can ultimately lead to us defeating the virus.

In the absence of a vaccine, we should expect to see more people infected when the lockdown is lifted. This is simply because the population will remain just as vulnerable as it was before the lockdown. At some critical point, transmission will stop and the epidemic will peter out, just like it has for similar infectious diseases in the past.

To estimate whether more Covid-19 deaths would have occurred without a lockdown would be, at best, a speculative exercise, prone to all the uncertainties inherent in modelling based on numbers with uncertain significance. We may never know.

Other fatalities

What about the impact of the lockdown on other causes of death?

Since the first Covid-19 case was reported in late January, there have been 559 confirmed deaths as on April 20 morning. During this roughly 75-day period, if we extrapolate data from recent years on mortality, over 1.5 million Indians will have died due to other causes. Thus, deaths due to Covid-19 account for 0.0002% of total deaths in this period. Most would agree that this is a vanishingly miniscule proportion.

About 1,000 persons die due to respiratory tract infections alone every day. These infections spread in similar ways to Covid-19. By forcing people into their homes, it is possible that their spread among people sharing crowded and insanitary housing would have, in fact, increased during the lockdown.

Simultaneously, there has been a dramatic reduction in the numbers of patients seeking medical care in many parts of the country. This is owing to a number of factors. Prohibition of public transportation has meant restricted access for those who cannot afford private vehicles. Private nursing homes have been unable to function as their staff cannot reach work.

Moreover, scarce public health resources have been reallocated to focus on Covid-19 preparedness. As a result, deaths due to deterioration in the care for chronic diseases such as diabetes, cancer, and heart disease may have increased as a result.

The number of suicides may also increase during this period. Women are at high risk of serious injury from violent partners from whom they cannot escape. And then there is the likely surge of deaths due to poverty which, according to some estimates, has affected 400 million workers – more than the entire population of the United States.

This toll will unfold in the coming months. Malnutrition in children is estimated to kill several thousand children every day. Now, these numbers could escalate further.

Meanwhile, mortality due to at least two causes will have plummeted during the lockdown: road traffic accidents and air pollution. The net reduction in loss of lives, the ultimate goal of the policy, may hang in the balance between these different factors.

Whichever direction the lockdown takes, there is little doubt that it has devastated millions of lives and livelihoods.

India’s testing strategy

Every policy requires thoughtful consideration of the costs and benefits. In my reckoning, it seems that the lockdown was implemented in too much haste, given the human tragedy that unfolded in the days following the announcement, with epic numbers of migrants trying to get back home evoking memories of Partition.

Paradoxically, this may have set the stage to exponentially expand the footprint of the epidemic to rural areas.

Relatedly, it is important to consider whether the lockdown should have been a progressive and dynamic policy – as is now being planned for its staggered lifting – focussing the most stringent controls in areas designated as “hotspots” and promoting less coercive strategies in other areas.

There are strategies that actually work, such as testing and contact tracing. But these would have required proactively collecting real-time data on the numbers of those infected in a standardised way so these numbers are comparable across time and space. This has been one of the weakest links in our response to the pandemic.

Despite the importance of testing, data from the Indian Council of Medical Research suggests that till April 9, only 150,000 tests had been conducted in the country, a per capita rate of testing amongst the lowest in the world.

Further, even these small estimates are impossible to interpret because the number and type of people tested has varied hugely over time and place. It does not take a rocket scientist to understand that the more one tests, the more one will find. Thus, the higher numbers of cases being reported in some states and as the lockdown has progressed may, at least in part, simply be a reflection of the greater number of tests conducted.

Then there is the question of who is tested. If random testing is conducted, the proportion of the infected population will be much smaller. Naturally, it will be higher if testing is only conducted on those who have fever and respiratory distress.

Without accounting for these caveats on the variations in testing strategy, daily reports and statistics splashed across newspaper front pages, their charting across time and states, and comparisons with other countries, have as much value to estimating the scale of the problem to counting grains of rice held by fists of different sizes.

What we should have expected by now is a standardised protocol being implemented in every state. For example: testing everyone who attends nominated Covid-19 hospitals with the recognised syndrome of symptoms and signs of the infection. Indeed, simply tracking the numbers of patients coming to any health-care facility with fever and respiratory distress could provide a more accurate picture of the unfolding of the epidemic.

Was the goal met?

Some argue that the impact of Covid-19 would have been much worse without a lockdown. They are right, but if saving lives is the sole goal of the lockdown, then it begs the question – why should the country not consider similar lockdown to reduce road traffic accidents and air pollution mortality?

India has, for many years, secured the leading place in the global ranking of mortality due to these two causes. The impacts on these would be even more dramatic and probably result in much larger numbers of lives saved. Yet, we seem to have shown no urgency in dealing with these known and avoidable factors.

This is because such stringent policies have unwanted adverse impacts. We are forced to consider all the possible scenarios and options, ultimately choosing a policy with the least likelihood of harm.

Furthermore, pre-emptive strikes in medicine are rarely justified. Consider, for example, the surgical removal of both breasts when a woman’s genetic code suggests a high risk of developing a rare form of breast cancer. One does not want the cure to be worse than the disease for those who would never develop the cancer in the first place.

When one balances the vast uncertainties of Covid-19 when the lockdown was imposed – at a time when there were just 10 deaths in the entire country – with the absolute certainty that such a lockdown would massively disrupt the lives and well-being of most of our population, it is hard to conclude that such a pre-emptive strike was justified.

What next?

But this is not the time to quibble with what is now history. The lockdown has happened and we are in the midst of it. The nation has showed remarkable solidarity with the policy and this is to be welcomed.

Rather, now is a time for us to consider the next steps and what lessons can emerge from this epochal event. The priority must be to restore the livelihoods of our poorest. This means restoring public transportation and the informal economy.

During the difficult months ahead, energies that would have gone into a National Register of Citizens survey can be diverted towards identifying those who are unemployed and guaranteeing at least a year of basic income pegged to the MGNREGA daily rates. I am no economist, but it seems to me that such a strategy would certainly go a long way in addressing hunger and destitution.

Simultaneously, we need massive investments in active case-finding, contact tracing, humane quarantining procedures, and strengthening our intensive care capacity. I am aware these strategies will require a lot of money, which is especially difficult in a tanking economy. But perhaps, this can be arranged for by imposing a one-year moratorium on arms purchases, which exceed billions of dollars.

In the long term, a fundamental lesson is not to plan epidemic containment policies solely on the basis of mathematical models built on assumptions and observations of other contexts. I believe the initial models that predicted apocalyptic numbers – and which have subsequently turned out to be so wildly off the mark that a random guess could have been more accurate – seeded some panic in the government.

I sympathise with the impossibly difficult dilemma and tight timelines that policymakers had to face. But there is an alternative: making strenuous efforts to obtain accurate local estimates of the numbers of cases from the first day. This, as I noted earlier, does not need to rely only on laboratory tests, as we can much more readily count the sick in the meantime.

Shaping the right policy

Policies must be appropriate, dynamic, and proportionate. This means their potential for harm must be taken into account while planning.

A one-size fits all approach for a country with such continental diversity should be avoided. It is utterly absurd, for example, to lock down my home state of Goa, which has witnessed zero deaths and just seven cases in total.

We must draw from past successes – such as controlling the Nipah and Zika outbreaks in Kerala and Rajasthan, respectively. Even as I write this, Kerala has yet again shown how to contain an epidemic in a manner that combines the values of humanity and science.

The crushing of hundreds of millions of livelihoods may lead to a surge of what Angus Deaton and Anna Case describe as “deaths of despair”, referring to the increased mortality among working-age Americans following the 2008 recession. These deaths are related to poor mental health arising from hopelessness and uncertainty about one’s future social and economic prospects, and are driven by suicide and alcohol abuse.

India’s mental health care system is its Achilles heel, with less than 10,000 mental health professionals in the country. Yet, the ingenuity of our scientists and civil society has time and again shown that community-based interventions is an effective and affordable strategy. This is a critical moment for the state and philanthropy to invest in such homegrown solutions to stem the tide of misery looming ahead.

Finally, a major lesson for the government and the media is to get its messaging right. They need to communicate accurately and proportionately. For example, instead of spreading panic by ghoulishly reporting meaningless numbers of those dying, they should promote stories that demonstrate the overwhelming majority of those who survive the infection.

Another example of needlessly stoking fear is the nonsense of generalising numbers of the dead from other countries to India without noting that the average age of Covid-19 mortality in Europe is 80 years and that many from this age group live in care-homes that are Covid-19 clusters. Barely 1% of India’s population is in this age group and almost none live in care-homes.

Communicating the age-stratified risk of mortality and indicating that a vast majority of our young workforce is not at risk might have stopped the biblical migration of millions to their villages and prevented stigmatisation of those who are infected or at-risk. Such an understanding would also have emphasised physical distancing in the home to minimise the risk of transmission to vulnerable elders.

India’s tryst with Covid-19 is far from over. It will continue to fester away for months, even years. Only time will tell what long-term impact the lockdown will have and whether the government was able to strike while the iron was hot.

But even beyond that, this will certainly not be the last epidemic of a novel infectious agent to hit our shores. It is crucial that we ensure the lessons from this experience will enable us to be better prepared to, or at the very least do no harm, the next time around.

This article first appeared on The India Forum.