Health

Lockdown 4.0: Centre Should Forget Red Tape and Stick to Five Principles

So far, no one has thought things through properly, which is why the sequencing of policy implementation has been flawed. This has to change if coronavirus infections have to be stopped and the economy saved.

The French philosopher Simone Weil, writing in 1934, probably had it right: ‘We are in a period of transition; but a transition towards what? No one has the slightest idea.’

Lockdown, a recent innovation, was first implemented by China in the two provinces of Hubei and Guangdong. The objective was to enforce the public health policy of social distancing by using state authority to ‘police’ the virus and disrupt its transmission.

While researchers found that strict measures of social distancing did effectively slow disease progression, they also entailed “great economic, psychological and social impact”. They cautioned that such measures should be “used as extreme options” and that “improved epidemiological surveillance and expanding the capacity to diagnose people with COVID-19” could provide options to decide on more specific and targeted strategies entailing lesser economic and social costs.

Unfortunately, the authorities in India never really weighed such options and allowed themselves to get into a panic that Freud calls “collective fear”. The sledgehammer of a national lockdown was used with no preparation or forewarning. Thousands of poor workers with bundles on their heads, streamed out of the lanes and bylanes of large cities heading home. For those living on daily earnings, hunger and destitution was staring them in the face, particularly when the lockdown was extended by another two weeks from April 15 till May 3. We are now in the third phase of the lockdown and Prime Minister Narendra Modi has already spoken of ‘Lockdown 4’.

Fifty days of lockdown have shaken the foundations of India’s fragile economy. The rumblings of a restless, impoverished migrant population, a restive industry, an agitated farming community and the large number of small businesses facing ruin could no longer be ignored. After all, in a  democracy, these sections, if not migrants, represent key electoral constituencies. While everybody knew economic growth would plummet, the coronavirus curve, contrary to expectations, is not showing any signs of bending. The intensity of the epidemic may have reduced somewhat but the infections are active – steadily increasing, even picking up pace with time.

This was the context for the first change in the government’s lockdown strategy. In its order dated May 1, 2020, the Ministry of Home Affairs listed out a series of exclusions, inclusions and partial restrictions to be implemented in different parts of the country with different intensities. The long-winded Kafekaesque order divided the country into three kinds of district-level zones – green, orange and red. There was also a general list of exclusions applicable throughout the country – essentially all activities that aggregate people – and a general list of inclusions for all zones. Finally, there were containment zones where the lockdown was to be enforced in its severest form.

It was recognized that the colour coding would be subject to constant review. Containment zones are also meant to be changing as the virus is chased down or spreads. Importantly, since the district zoning has been done by the Central government, any changes to the list require its prior concurrence – an issue that has caused some dissonance with state governments.

Implementation challenges

The concept of zoning arose from the need to rationalize the public health demands of physical distancing with the need to allow human transactions and economic activity. Likewise, taking the district, instead of the state, as a unit, made sense since it is the district that in our scheme of governance provides cohesive leadership and clarity in the boundaries of authority. Accordingly, it becomes administratively appropriate to categorise districts in accordance with the disease burden so as to ensure that resources and policy attention are not spread thin but stay focused where needed most. Once areas/ wards/ towns/ villages are identified as hotspots within the districts, interventions of active case finding by testing, tracing and isolating can be effectively implemented, mitigating the spread while at the same time not inconveniencing the rest of the population in general.

Conceptually, therefore, the inter- and intra-district zoning is sound and close to the strategy that India innovated to fight HIV AIDS with great success. But there is a difference. In the case of HIV AIDS, once the infection pathways were traced out, they stayed long enough till interventions strategies could be effectively implemented.

In the case of COVID-19, however, the designing of the interventions is complex and challenging due to the large number of uncertainties and knowledge gaps: the huge proportion of asymptomatic infections; the possibility of cured persons getting reinfected; the variance in understanding the incubation period and so on. This poses a challenge in defining a containment zone.

For example, if there is one positive case in an apartment complex, why do people in a 3 km radius have to be quarantined? If not, how do we know there are no asymptomatic carriers in that complex who can continue spreading the infection? Besides, even after sanitising the red zone and declaring it green, it can once again get new cases of infections as is happening in Wuhan and South Korea. With extensive dos and don’ts linked to the emergence of infections, constant changes of classification can be confusing for administrators as for the people, wearing their patience and morale down.

Besides, the MHA order has created a contrarian nightmare. While some manufacturing industries, including construction, have been permitted, migrant labour have been allowed to go home. So, on the one hand, thousands of migrant workers are either walking home or thronging railway stations to be taken home, on the other, industries are stuck without labour. Neither can be blamed. Since the small industries and factories had no income, payment of salaries for April was difficult. On the other hand, the administration did not engage with industry to ensure that food and essentials were provided in adequate quantities to their labour.

Traumatised by having to live on charity, on one meal or staying hungry, coupled with yet a further extension of the lock down to May 17, resulting in the loss of trust in the government, migrant workers are a desperate lot set on returning home to rebuild their wrecked emotional stability. But if they had to go home, they should have been allowed to go in the first phase of the lockdown. In the last week of March, when caseloads were in two digits, the workers were not helped to return home. But now, when the likelihood of many being infected is high, they are being transported back. Clearly, no one has thought things through properly, and the sequencing of policy implementation has been flawed.

The way forward

In reality, implementing the current guidelines can be challenging as they are prescriptive, and lack clarity about where discretion is permissible and which principles are non-negotiable. Absence of such clarity and laying down boundaries of decision making are a sure recipe for unending bureaucratic red tapism, harassment and corruption. Given the volatile situation where infections appear and disappear in a manner that cannot be pre-determined or foreseen, guidelines ought to be simple, direct and facilitative by being grounded in the objective to be achieved and the principles to be adhered to.

There is no doubt that the manner in which the lockdown has been implemented means the quantum of cases will increase and there is going to be a surge, as the peak will be reached once the lockdown is lifted. If the numbers increase beyond the coping capacity, government will need to take a call – enforce a national lockdown again; or open it up but aggressively increase testing, case finding, isolating and enforcing preventive behaviour. Whatever be the pathway chosen, it is essential that government urgently does the following:

1. Simplify the guidelines into two categories: containment zones and free zones. A strict definition of the containment zone needs to be laid down, and an enforceable area – that does not cause too much harassment – cordoned off till sanitization efforts are completed. In the free zone, allow restoration of normalcy in a graded, incremental manner by resorting to staggered timings for shops and offices, alternate school days and such strategies to avoid crowding. The focus on instilling and enforcing preventive behaviour in public areas must be instilled as the new normal. For this, citizens need to be engaged with. This will be possible only when people understand what and why.

2. Uniformity in the definitions and strategies: It is time the Government of India comes out with clear testing, treatment and epidemiological guidelines that are uniformly enforced. In the absence of such uniformity, a state like Telangana keeps extending the lockdown without any justification, causing immense hardship to the people. In other words, there is need to develop strict epidemiological criteria that a state or district must fulfill for imposing lockdowns and curtailing freedoms and matters should not be left to the discretion of the concerned chief ministers;

3. Decentralization to districts and making district collectors lead the effort at the district level is important. Districts must be made to prepare micro plans laying down the strategies being followed, what to open when and where, transportation routes, the community leaders and NGOs being engaged, location of relief camps, food kitchens, quarantine centres etc. Such information in the public domain will generates confidence and cooperation.

4. Expand testing, particularly in the 100-odd districts / cities that have had a high disease load. In these geographies free testing and counselling services must be scaled up to saturation levels to help identify asymptomatics too. Ease of access being critical, there should be more mobile testing facilities, particularly in densely populated areas that cannot maintain social distancing and have high probabilities of infection.

5. Intensively engage civil society to i) remove stigma, ii) encourage people to come forward for testing, and iii) managing the quarantine centres to be clean and comfortable; iv) identify the homeless and the poor who may not have Aadhaar cards to get access to basic essentials, undertake mass media campaigns to educate the people with information; establish call centres for complaints and enquiries etc.

Conclusion

India has not peaked as yet. We are still in the secure bubble of the lockdowns. As normalcy returns, which it has to, the real spread of the infections will emerge. It is important to calm ourselves and not get hysterical or fearful. Instead of fighting the virus, we need to accept it as a part of our reality. The only option we have is to save ourselves from getting the infection by adhering to preventive measures and protecting the vulnerable populations – the elderly and those with co-morbidities. Hospitals and clinics need to ramp up their infection control procedures and begin to treat non-COVID cases. More than the infections, we need to battle the fear that we seem to have got into our psyche and ensure that in so doing we do not become complacent either. For we need to remember always that “there are very few threats that can be compared with infectious diseases in terms of the potential to result in the catastrophic loss of life”. We have a chance only if we live with a sense of social solidarity and social responsibility.

K Sujatha Rao is a former Union health secretary