As the 40-day national lockdown to protect us from the Covid-19 epidemic has been extended further till May 17, 2020, it is time to take stock of the situation and try to answer these questions as objectively and as truthfully as we can: (1) How necessary was this lockdown? (2) How effective has it been in arresting the spread of the disease? And (3) how to get out of it in the coming days and get back to the normal life?
This is perhaps the first instance in the world in which a huge country of 1.35 billion people has been completely shut down to save us from the epidemic of a viral infection, and that too right in the beginning, when the epidemic had just started.
And yet, the whole country has rallied behind this decision and all of us have done our best to follow the rules of social distancing and lockdown. It is heartening to see the whole country coming together and rallying behind the national and state governments at the time of crisis. Despite this support, it is important to raise and answer these questions.
How has lockdown progressed?
By the end of March 24 (when the lockdown was declared), total number of confirmed cases were 469 (i.e. 0.35 per million) from which 10 persons had died. The daily incidence of new cases were 95 (i.e. 0.06 per million per day). All these cases were confined to those who had returned from foreign travel and their family members and others who had come in direct contact with them.Incidence of new cases continued to increase after March 25, after the total lockdown. It reached to 600 (0.40 per million) per day by April 6, 1,300 (0.96 per million) per day by April 14, about 1,700 (1.26 per million) per day by April 28 and 2,600 (1.81 per million) per day on May 3 and jumped to 3,400 (2.54 per million) per day by May 6. Total number of cases from March 1 to May 6 have been 49,391 (36 per million) and total deaths have been 1694 (1.25 per million) and 3% of the total cases.
These cases are spread over many states and not concentrated in one or two states. We should also note that these are all cases of patients who have tested positive, irrespective of symptoms. They include all those who have no symptoms or mild symptoms requiring no hospitalization, mild to moderate symptoms and critical symptoms.
No data is publicly available on how many patients are in which category. But all reports indicate that about 80% cases have no or very mild symptoms, 15% have mild to moderate symptoms, who may require hospitalization and only 5% have severe to critical symptoms, who require critical care including ventilators. Indian Council of Medical Research (ICMR) representative also said during a recent press briefing that 80% cases are asymptomatic with no symptoms.
The best way to achieve that in the early days was to quarantine all persons coming from key foreign countries with Covid-19 epidemic for 15 days. That would have ensured that even if anybody of them had the infection, they would get cured before going to and mixing with their families. But we did not do this.
Instead, we only screened these persons and isolated only those who had symptoms. This allowed many possible asymptomatic carriers to pass through and start spreading the disease in the community. Even then, in March all cases were still mainly of those who had come from foreign trips and their direct contacts.
Hence, the easier option than locking down the whole country would have been to identify all those who had returned from certain foreign countries in the last one or two months and isolate them and their family members/ other direct contacts for 15 days.
Most of the health experts, both those associated with the government and others, have been arguing that the goal of this lockdown was not to eliminate the virus, but to lower the peak – to flatten the curve – to ensure that our health infrastructure is not overrun by large number of cases leading to loss of life.
This is the most persuasive argument that has influenced most of us in supporting the lockdown. But here also, the question remains – even if true, what was the need to enforce this lockdown so early, when the epidemic had just started?
All models, which show that measures of social distancing and lockdowns can help in reducing cases and hence deaths, also show that to be effective they should be enforced not early but later after herd immunity is significantly developed. They suggest that the week after the incidence of daily new cases has peaked and started decreasing, is perhaps the best time for implementing these measures.
The same models also show that implementing these measures at the start of the epidemic not only flatten the curve, but also lengthen it, i.e., prolong the epidemic and also cause the epidemic to rebound once these measures are lifted, because no herd immunity is developed.
One such model shows that even if we implement such early lockdown for an extended period of 4 months, the herd immunity would not be created and the epidemic would rebound after the lockdown and can last for nine months. Clearly, herd immunity is the thing that ends epidemics and all other efforts that we may make to reduce the number of deaths, should be initiated after first building this immunity.
Also, if the goal was to prevent overloading of the health institutions and thereby prevent deaths, then the best way was to concentrate all energy and focus only on those 10-15% of vulnerable people, who could develop serious life threatening symptoms and not on the remaining 85-90% people who have no or mild symptoms.
No data is publicly available on how many patients are in which category. But all reports indicate that about 80% cases have no or very mild symptoms, 15% have mild to moderate symptoms, who may require hospitalization and only 5% have severe to critical symptoms, who require critical care including ventilators. Indian Council of Medical Research (ICMR) representative also said during a recent press briefing that 80% cases are asymptomatic with no symptoms.
How necessary was the lockdown?
It is argued that we had already seen the havoc this disease had caused in the other countries and hence it was necessary to take a decisive action right in the beginning to ensure that we nip it in the bud and do not allow it to get a foothold in our country. That was certainly a worthy goal and nobody can object to it. But the question still remains – was it necessary to lockdown the whole country to do this?The best way to achieve that in the early days was to quarantine all persons coming from key foreign countries with Covid-19 epidemic for 15 days. That would have ensured that even if anybody of them had the infection, they would get cured before going to and mixing with their families. But we did not do this.
Instead, we only screened these persons and isolated only those who had symptoms. This allowed many possible asymptomatic carriers to pass through and start spreading the disease in the community. Even then, in March all cases were still mainly of those who had come from foreign trips and their direct contacts.
Hence, the easier option than locking down the whole country would have been to identify all those who had returned from certain foreign countries in the last one or two months and isolate them and their family members/ other direct contacts for 15 days.
Most of the health experts, both those associated with the government and others, have been arguing that the goal of this lockdown was not to eliminate the virus, but to lower the peak – to flatten the curve – to ensure that our health infrastructure is not overrun by large number of cases leading to loss of life.
This is the most persuasive argument that has influenced most of us in supporting the lockdown. But here also, the question remains – even if true, what was the need to enforce this lockdown so early, when the epidemic had just started?
All models, which show that measures of social distancing and lockdowns can help in reducing cases and hence deaths, also show that to be effective they should be enforced not early but later after herd immunity is significantly developed. They suggest that the week after the incidence of daily new cases has peaked and started decreasing, is perhaps the best time for implementing these measures.
The same models also show that implementing these measures at the start of the epidemic not only flatten the curve, but also lengthen it, i.e., prolong the epidemic and also cause the epidemic to rebound once these measures are lifted, because no herd immunity is developed.
One such model shows that even if we implement such early lockdown for an extended period of 4 months, the herd immunity would not be created and the epidemic would rebound after the lockdown and can last for nine months. Clearly, herd immunity is the thing that ends epidemics and all other efforts that we may make to reduce the number of deaths, should be initiated after first building this immunity.
Also, if the goal was to prevent overloading of the health institutions and thereby prevent deaths, then the best way was to concentrate all energy and focus only on those 10-15% of vulnerable people, who could develop serious life threatening symptoms and not on the remaining 85-90% people who have no or mild symptoms.
Was it necessary to stop migrant workers from going home?
Figures suggest that if the lockdown was to be implemented at all, there was no reason why lakhs of migrant workers could not have been given sufficient time and transportation that would have allowed them to reach their homes, before the lockdown was implemented.
As we know, not only were they given no such time and transportation, they were not even allowed to walk back to their homes on their own and were stopped on the way and locked in schools and other makeshift arrangements, creating a huge humanitarian crisis.
It has been argued that it was necessary to do this, as otherwise these workers would have carried the Corona virus with them to their home towns and villages and started spreading this disease there, which would have defeated the whole purpose of the lockdown. These figures, however, tell us that there was no factual basis for this fear.
Given the fact that at that time, only 1 in 2.7 million people (0.36 per million) had this disease by 24 March and that too in a specific group of people returning from foreign travel and their direct contacts.
It has been argued that it was necessary to do this, as otherwise these workers would have carried the Corona virus with them to their home towns and villages and started spreading this disease there, which would have defeated the whole purpose of the lockdown. These figures, however, tell us that there was no factual basis for this fear.
Given the fact that at that time, only 1 in 2.7 million people (0.36 per million) had this disease by 24 March and that too in a specific group of people returning from foreign travel and their direct contacts.
Thus the probability of these migrants having been infected and thus carrying the virus at that time was virtually zero and that fear was imaginary. By not allowing them to go home, an impression was created that they were carriers of Corona, who must be stopped!
This led to so many instances of absolutely inhuman treatment meted out to them – like making them walk on their knees, sanitizing them by spraying them with harmful solutions, locking them up in schools and not opening the locks even for giving food and also filing criminal cases against them for breaking rules of the lockdown! This heatless treatment meted out to these poor helpless people would go down as the biggest blot on this lockdown.
This led to so many instances of absolutely inhuman treatment meted out to them – like making them walk on their knees, sanitizing them by spraying them with harmful solutions, locking them up in schools and not opening the locks even for giving food and also filing criminal cases against them for breaking rules of the lockdown! This heatless treatment meted out to these poor helpless people would go down as the biggest blot on this lockdown.
Was the lockdown effective?
Total lockdown right from the beginning has not nipped the epidemic in the bud. On the contrary, figures show that after enforcing this lockdown, total number of cases has increased from 469 on March 24 to around 49,391 on May 6, and have continued to increase.
Deaths have increased from 10 to 1,694 on May 6, and have continue to increasing. And daily incidence of new cases has increased from 95 (0.06 per million) per day to 3,400 (2.54 per million) per day during this period.
These figures also show that no flattening of curve (reducing the number of new cases per day) has happened. We see some signs of flattening during April 12-17 and then in the last week of April, but thereafter the curve has started rising steeply.
Similarly, if the curve is flattening, then the trend line of total cases should be seen as flattening. But figures also clearly show that far from flattening, the number of cases is actually growing exponentially.
These figures also show that no flattening of curve (reducing the number of new cases per day) has happened. We see some signs of flattening during April 12-17 and then in the last week of April, but thereafter the curve has started rising steeply.
Similarly, if the curve is flattening, then the trend line of total cases should be seen as flattening. But figures also clearly show that far from flattening, the number of cases is actually growing exponentially.
Lockdowns and social distancing can at best slow down what is happening to a certain extent, not fundamentally change the situation
We may also note that we have been admitting all confirmed cases of Covid-19 to hospitals for a minimum period of 15 days, irrespective of symptoms. This has led to unnecessary overcrowding of the hospitals (Ministry of Health and Family Welfare issued guidelines on April 27 allowing home isolation for patients with no or very mild symptoms).
Overall death rate in our country is only 3% of all confirmed cases. But if we take into account the fact that as many as 80% of these cases are without any symptoms, the case fatality ratio for all symptomatic cases comes to 17%, which is very high.
Our situation in comparison with that of other countries/regions indicates that our response of extreme measures and widespread support in the society for these measures are perhaps guided more by the fear of what has happened in these countries than the actual situation in our country.
It is claimed that the situation is better in our country because of the timely lockdown right in the beginning. But this is certainly not true. Lockdowns and social distancing can at best slow down what is happening to a certain extent and not fundamentally change the situation. And if that was indeed the case, then it would have got reflected.
Overall death rate in our country is only 3% of all confirmed cases. But if we take into account the fact that as many as 80% of these cases are without any symptoms, the case fatality ratio for all symptomatic cases comes to 17%, which is very high.
How serious is this crisis at present?
It is clear that even now, after 60 days from March 3, when the cases started appearing, the situation in our country is still not critical. We can only realize how fortunate we are, when we compare our situation with that of other countries/ regions, which are really in a crisis situation.Our situation in comparison with that of other countries/regions indicates that our response of extreme measures and widespread support in the society for these measures are perhaps guided more by the fear of what has happened in these countries than the actual situation in our country.
It is claimed that the situation is better in our country because of the timely lockdown right in the beginning. But this is certainly not true. Lockdowns and social distancing can at best slow down what is happening to a certain extent and not fundamentally change the situation. And if that was indeed the case, then it would have got reflected.
More likely explanation is that this epidemic has been much milder in our country with very low incidence of cases that are increasing very slowly till now. This is not true only for us. The above table also shows that the countries of South East Asia also have similar milder epidemic, although most of them have not imposed lockdowns. Similarly, Australia and New Zealand have also experienced a mild epidemic.
This may be either because the strain of the virus in these countries is mild with less infectivity than the one that went from South Korea to Iran to Italy to New York. Another reason of the mild epidemic in our country is that the virus entered our country only in the first week of March, when the flu season of winter had almost ended and that might have made more difficult for the virus to transmit.
But another possibility is that this epidemic in our country is also not mild. The figures are still low, because it started late in our country, and our country being large and diverse, the epidemic is taking more time to develop into a full blown crisis. The way the cases have increased from about 40,000 to 50,000 in just three days clearly shows that the cases are still increasing and that there is really no room for complacency.
The focus still is on breaking chains of transmission and containing the spread of the disease. But it is clear that when this approach has not worked so far, when the epidemic had just begun and cases were few, there is no chance of it working now, when the cases are increasing exponentially. This and the fact that it is the herd immunity that ends the epidemic, suggest that we need to change our approach radically.
Instead of spending our time, energy and resources on the impossible task of stopping the disease from spreading, we need to remove all restrictions and allow it to spread amongst those who are not vulnerable, so that herd immunity is quickly built. And focus all our energies on protecting the elderly and those with comorbidities of serious disease to ensure that they do not get this disease as far as possible and get timely proper treatment, if they get it.
Renowned epidemiologists like Dr. Jayprakash Muliyil of Vellore have been recommending this approach from before 14th April, when the first 21-day lockdown ended. It is high time that we heed their advice now.
This may be either because the strain of the virus in these countries is mild with less infectivity than the one that went from South Korea to Iran to Italy to New York. Another reason of the mild epidemic in our country is that the virus entered our country only in the first week of March, when the flu season of winter had almost ended and that might have made more difficult for the virus to transmit.
But another possibility is that this epidemic in our country is also not mild. The figures are still low, because it started late in our country, and our country being large and diverse, the epidemic is taking more time to develop into a full blown crisis. The way the cases have increased from about 40,000 to 50,000 in just three days clearly shows that the cases are still increasing and that there is really no room for complacency.
What should be done now?
As we know, the lockdown has already been extended up to May 17, albeit with certain relaxations. All districts of the country have been divided into red, orange and green districts for this purpose and green districts have been given maximum relaxations, while the red ones have been given least relaxations.The focus still is on breaking chains of transmission and containing the spread of the disease. But it is clear that when this approach has not worked so far, when the epidemic had just begun and cases were few, there is no chance of it working now, when the cases are increasing exponentially. This and the fact that it is the herd immunity that ends the epidemic, suggest that we need to change our approach radically.
Instead of spending our time, energy and resources on the impossible task of stopping the disease from spreading, we need to remove all restrictions and allow it to spread amongst those who are not vulnerable, so that herd immunity is quickly built. And focus all our energies on protecting the elderly and those with comorbidities of serious disease to ensure that they do not get this disease as far as possible and get timely proper treatment, if they get it.
Renowned epidemiologists like Dr. Jayprakash Muliyil of Vellore have been recommending this approach from before 14th April, when the first 21-day lockdown ended. It is high time that we heed their advice now.
This approach of allowing the epidemic to spread to end it, is no doubt, counter intuitive and hence difficult to accept. And at the time when cases are growing exponentially, it is even scary. But we should not forget that in practice it is the herd immunity alone that ends the epidemics (unless we have a vaccine).
And regarding increasing cases, we should not forget that 80-90% of them are asymptomatic or with mild symptoms only and do not require any hospitalization, let alone critical care. Thus, even with 50,000 positive cases, we have only 5000-10,000 patients, who may require hospitalization and those requiring oxygen or ventilators would be only 2500 to 5000! Adopting this approach means that:
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*With Action Research in Community Health and Development (ARCH-Vahini), based in Gujarat. This is the abridged version of the author's discussion paper
And regarding increasing cases, we should not forget that 80-90% of them are asymptomatic or with mild symptoms only and do not require any hospitalization, let alone critical care. Thus, even with 50,000 positive cases, we have only 5000-10,000 patients, who may require hospitalization and those requiring oxygen or ventilators would be only 2500 to 5000! Adopting this approach means that:
- We stop all efforts to identify and isolate all infective cases and their contacts. This has not worked so far, and is impossible to implement with increasing cases.
- End lockdown and remove all restrictions on industries, businesses, public transportation by road, rail and air and also open schools and colleges, as quickly as possible.
- End compulsory enforcement of rules of social distancing – wearing masks, maintaining two-meter distance, etc. Those who want to follow them can of course continue to do so.
- Protect elderly and other at risk persons with serious ailments from getting this infection by advising adherence of strict social distancing (masks, distance, etc.) at all times, even within homes. And as far as possible, they should remain in separate room with minimal contact with other members of the house.
- Provide timely treatment to them as soon as they show first signs of Pneumonia or difficulty in breathing.
- Allow all hospitals / physicians to treat Covid-19 patients with a condition that they shall provide daily reports of all patients being treated by them and their condition. This would ensure that all existing health infrastructure is available for the treatment of this disease.
- Continue to monitor the situation very closely, to know how the epidemic is progressing. Randomized sample antibody tests should be carried out at regular intervals, to know how far we are from developing herd immunity. This is totally different from what we have been doing so far and hence difficult to accept and implement.
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*With Action Research in Community Health and Development (ARCH-Vahini), based in Gujarat. This is the abridged version of the author's discussion paper
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