India’s harsh lockdown didn’t work. What can be done now to slow the spread?

India woke up late to the coronavirus pandemic. Even as the infection was sweeping through a number of countries, the Indian government kept international flights open for most of March – a critical mistake that allowed people infected with Covid-19 to enter the country in significant numbers.

However, India tried to make up for a late start by clamping down with the world’s harshest lockdown. Starting March 24, Prime Minister Narendra Modi ordered a complete lockdown across the country, in a bid to stop people-to-people interactions and slow the spread of infections.

This lockdown lasted for 75 days until the Union government started what it called “Unlock 1” from Monday.

In spite of the severity of the lockdown, however, India has struggled to control its cases. “Under India’s lockdown, the curve did not bend,” said T Sundaraman, the former executive director of the National Health Systems Resource Centre, an advisory body to the health ministry.

Over the past week, India’s cases have grown at one of the fastest rates across the world, according to data compiled by Bloomberg.

Not only did India see its cases shoot up, even the geographical spread of the infection was not contained with lockdown. On April 6, for example, India had 417 districts without any cases. Two months, this figure has come down to 49.

“In a large population like India, it was always clear that a lockdown would not work,” said epidemiologist Jayaprakash Muliyil. In an interview to Scroll.in before India announced its lockdown, Muliyil had cautioned against the use of total lockdowns, arguing that it would do more harm than good.

Instead, Muliyil now urges the government to adopt local, targeted action and focus on community participation. “We need to focus on vulnerable populations like the elderly,” he explained. “And we need to make sure everyone is wearing a mask.”

Context versus cause

Virologist Jacob John agrees with Muliyil on the fact that India’s lockdown did not succeed. “We blindly copied the lockdown from places like the United Kingdom,” argued John. “In reality, the government had no idea what a lockdown meant. It was a highly irresponsible act. And now we are lifting the lockdown when cases are shooting up.”

John argues that rather than using the blunt instrument of a lockdown, India must take a smarter approach: “The context of transmission is social interaction. It spreads during social interaction – but not because of social interaction. Infection spreads because droplets are ejected by one person and the other person inhales them.”

John elaborated: “Just because cholera spreads through the water supply, doesn’t mean you shut off the water supply, does it? We filter the water.”

John recommends behavioral changes over a draconian lockdown. “Universal mask wearing is twice as effective as lockdowns,” argues John. “As the lockdown is lifted, it must be replaced by public education about wearing masks. I barely see anyone wearing a mask. Like we make sex safe [to prevent HIV], we should also take steps to make breathing safe.”

One study by the United Kingdom’s University of Cambridge suggest that the widespread use of masks can even help end the epidemic. One scenario modelled out by the study shows that if everyone were to wear a mask of just 75% effectiveness – thus even homemade one would do – it could bring a very high “reproduction number” of 4.0 (which the UK was close to before its lockdown) down to under 1.0, even without the use of lockdowns.

The reproduction number refers to the average number of people a person with Covid-19 infects. A number less than one, means the disease will, over time, die out.

Isolate spreaders

T Sundaraman, the Executive Director of National Health Systems Resource Centre in New Delhi,
says that another lockdown can never be “ruled out” but he was unsure about how effective it would be: “A lockdown is a temporary measure, like using a raft. You can’t actually live on the raft.”

Sundaraman identifies symptomatic patients as the main focus area for governments rather than using a lockdown that restricts everyone. “The main focus must be contact tracing and isolation of people who have the infection,” he explained. “If ill patients are going around looking for care, they will spread the disease. This is what I am worried about: Covid-19 symptomatic patients moving around.”

Last Saturday, for example, a man with full blown Covid-19 travelled by train from Delhi to Bhopal after failing to even get tested in the capital in spite of visiting as many as five hospitals. “He had visible symptoms of distress, yet it did not raise alarm bells at Delhi or Bhopal railways station,” reported the Times of India, quoting an official. The man, who died on Sunday, could have potentially exposed hundreds to the disease.

Gautam Menon, professor of Physics and Biology at Haryana’s Ashoka University and an expert in disease modelling, argues that India’s lockdown did have an effect in decreasing cases – but India should not consider another country-wide lockdown again. “Local targeted lockdowns could be used if cases are going out of control in a particular area,” he explains. “That should be decided in terms of that area’s ability to cope with things like hospitals beds, ICUs etc. But that should be a local decision to take.”

Menon argues that the first lockdown had a critical role to play in making people aware of the pandemic and that they would have to take precautionary measures. “Right down to the villages, every Indian is now aware of the coronavirus pandemic – that’s quite an amazing task given we have 1.38 billion people.”

Given this awareness, Menon thinks nimble, local containment measures are the best way to take mitigation forward. “Right now there should be general country-wide guidelines but all decisions around restrictions have to be made at the local level.”