A lockdown can mean different things in different contexts. In the context of the current COVID-19 pandemic that originated in Wuhan, China, and spread across almost 204 countries, the term has been used for varying limits on movement, function and activities of communities. It isn’t a technical public health term, and ranges from mandatory quarantines to non-mandatory recommendations to stay at home, close certain types of businesses or avoid events and gatherings.
There have been several discussions around the COVID-19 infection and its potential to cause fatality, India’s preparedness and the lessons learnt. This analysis attempts to understand what a lockdown means in the context of public health in India.
The lockdown according to a few other countries
Different countries have interpreted and implemented lockdown differently. The most significant intervention by China was the quarantine imposed on January 23, 2020. Along with this, the country also restricted public access to information, including that shared by Dr Li Wenliang, who was detained for posting online about the virus and who later died of the infection himself.
In February 2020, two journalists disappeared after continuously reporting stories about the outbreak. In an attempt to create a good online atmosphere, many social media apps and accounts were removed because of ‘harmful content’. The media had to cover only positive stories about the relief work being done by Chinese authorities. The government’s agenda seemed to stretch beyond virus control and into social control.
It is important to understand that China has suffered socially and economically not just because of the virus but because of government policies as well. Though China followed a high-end surveillance system, it was not done with people’s participation or even understanding. The state’s self-promotion took precedence over access to information. One reason for the Chinese lockdown was damage control, as the infection had reached a point where global opinion had to be urgently addressed.
Taiwan, because of political pressure from China, is excluded from the WHO but unlike China focused itself on making information available to the people. The Taiwanese government has been preparing since late December 2019 and also set up a Central Epidemic Command Centre. State officials have been holding press conferences every day to announce the latest policies and updates on the epidemic, and to clarify rumours on social media.
Many Taiwanese officials used their official social media accounts to share even small details with the public. Civil society worked with the government to fill gaps, publish real-time maps and create fact-check centres. Such initiative allowed its people to actively participate in the implementation of government policy. Taiwan followed the logic of a democratic state as opposed to China’s authoritarian state.
The Russian parliament passed laws to impose harsh punishments for rule-breakers; those breaking quarantine or spreading misinformation faced up to five years in prison. ‘Misinformation’ in the time of COVID-19 could also mean criticism of the government. The pitfalls of this are obvious.
New Zealand entered a month-long national lockdown on March 25 as the number of cases in the country rose by nearly 50% in a short span of time. The lockdown is expected to be eased partially if the case increase rate slows. At the time of announcing the lockdown, New Zealand’s prime minister said, “I say to all New Zealanders: the government will do all it can to protect you. Now I’m asking you to do everything you can to protect all of us. Kiwis – go home.”
Contrast this with the Indian government which, going by its actions since the lockdown, seems to say that it absolves itself of all responsibility and leaves to its citizens the responsibility of handling the situation, and failing which they will be punished even if it means losing jobs, rights, livelihood, dignity, food, and education.
The scenarios in New Zealand and India are both lockdowns, but in the first, the government takes primary responsibility to help its citizens tide over a difficult period.
The authoritarian lockdown
Some predictable fallouts of an authoritarian lockdown include:
1. Suppression of data at all levels because of the culture of shaming those who show ‘poor outcomes’ and rewarding those who show ‘good outcomes’. Officials in India have already mastered the art of reducing the incidence of diseases of concern, and there is no reason to believe they won’t draw from these skills in the context of COVID-19 as well. In India, there is evidence that target setting, punitive action and hierarchical structures lead to magical drops in numbers. We have seen this with family planning, institutional deliveries, maternal/infant deaths, tuberculosis, HIV, malnutrition, dengue, malaria, manual scavenging, lynchings, domestic violence and dowry deaths. There is a difference between a government that wants to genuinely provide healthcare and government that simply wants to look good.
2. The government has failed to proactively publicise major decisions, whether demonetisation, the reading down of Section 370 or the ongoing lockdown. The idea of people being participating stakeholders is being actively eroded, leading to a corrosion of trust and avoidable delays in response. If an authoritarian government announces that community spread is imminent, it is almost certain that the spread already occurred sometime back. In disasters like earthquakes, the authoritarian state may be able to provide disaster relief but this doesn’t work in the case of a pandemic. To track and control the spread of a virus, there is a need for information to flow freely and without being linked to punitive action.
3. Under an authoritarian state, people may function like coerced subjects rather than informed stakeholders, doing only as much as they have to and often tending to breaking boundaries and rules. The relationship of civil society and media to the government will resemble that between a cat and mouse, with attempts to thwart each other, rather than to work together towards shared goals. This is the crucial difference between how epidemics are controlled by authoritarian governments and by democratic governments.
4. To maintain the image of success, the government is likely to be even more authoritarian than is acceptable under normal circumstances but uphold its measures as ‘necessary’ – the so-called ‘cruel to be kind’ intervention. Less than a month ago, state officials slapped sedition charges on mothers and teachers for a children’s play enacted in Karnataka. It is unlikely for the government to now suddenly turn benevolent because of COVID-19.
5. The people of India have already largely been polarised into two groups: those who believe the government can do no wrong and those who demand that the right to a COVID-19-free world doesn’t automatically trample on rights and civil liberty. The lockdown shows that while the rights of some become limited, for others like the labourers it is an existential right connected to their food, dignity and livelihoods. Additionally, people who have moved out of cities have also increased the virus’s geographic spread.
6. Guidelines in other countries allow ‘essential’ travel. In India, this means a large part of the country will continue to travel as their income depends on it. The sheer numbers would itself mean that a lockdown is not possible. Seen differently, a lockdown where essential travel is curbed is bound to impinge, often adversely, on several human rights.
7. The lockdown can lead to health issues that can render people more vulnerable to COVID-19 and related complications once the lockdown is lifted. India has a high burden of diabetes and hypertension, both conditions exacerbated by cereal-heavy diets. With the lockdown, the food security of a large number of people has been endangered, and they are unable to procure medicines or access screening tests. Those with uncontrolled diabetes, hypertension and heart disease are at high risk for the complications of COVID-19 infection. In effect, a poorly planned lockdown makes vulnerable communities more susceptible to complications and increased mortality.
8. Many norms of confidentiality and privacy of patients and their contacts are being violated on the pretext of a lockdown. These norms have been laid down to protect against stigma and discrimination which can potentially lead – among other things – to harassment, denial of care, negligence and loss of employment, particularly among those with leprosy, tuberculosis and HIV/AIDS. There is no reason to believe these ethical concerns should be set aside in a pandemic and there is no known benefit of community policing of individuals. With the information about COVID-19 trickling in, people and communities are already being evicted and bullied. The criminalisation has also meant people are afraid to get tested.
India already has a history of discrimination based on gender, caste, class, ability and sexual orientation.There is no reason to believe society will become automatically inclusive in the wake of COVID-19. These barriers will continue to make it difficult for everyone to access health services and avail of testing.
9. The communal nature of the government and its supporters comes out even in a pandemic. Even as the government issued a notice that false information about COVID-19 will be strictly punished, communalised misinformation and hate continues unchallenged. Fake news about Muslims is being spread rapidly leading to social and economic boycott of Muslims across the country. It is of concern that a pandemic has put the lives and livelihood of Muslims in India at risk.
An authoritarian lockdown thus could prioritise the ends over the means. The graph becomes everything – like a man burning his house down to keep the candle alight.
After lockdown, what?
1. What if, once the coronavirus pandemic winds down, there is a new infection that requires, among other things, the government to lockdown the country for a longer period? Once the government gains absolute control, can it at any point be brought back to a ‘pre-COVID’ state? We need specific rules that define when the government can impose a lockdown, how, for how long and finally how the lockdown can be wound down.
2. What happens if India removes the lockdown and the number of people who test positive for the new coronavirus begins to rise again? Will the lockdown be reimposed? Have the other – especially economic – consequences of an extended or repeated lockdown been adequately assessed? Who decides what damage to society due to the virus as well as the lockdown is acceptable?
3. Overcrowding leads to a higher risk of many diseases like tuberculosis, scabies, respiratory infections and gastrointestinal infections. Why was overcrowding in slums, buses, garment factories, industries and manufacturing units never seen as a problem until now?
4. Why are houses with good ventilation and adequate spacing never part of any housing plan? Why hasn’t public transport been so widely available that people could sit apart from each other? Why are workplaces, especially in the informal sector, so cramped? Why are prisons and shelter homes so overcrowded? Is the government doing anything to reduce this kind of overcrowding – a risk factor for a host of other infections apart from COVID-19?
Testing and physical distancing
Let us assume a daily-wage labourer in a village in Karnataka develops a high fever and cough. He or anyone in his village is unlikely to have as much information as a corporate employee in Bengaluru. His primary source of information about the infectious disease would be rumours and WhatsApp forward. If suspected of a COVID-19 infection, It is quite possible that the responses of the family and the community at large would be to ostracise him, not just maintain physical distance. The most recent disease we saw this with was HIV. Stigmatised people face real outcomes of discrimination and stigma, arising out of manufactured information.
The other possibility is that the man has COVID-19 but is unaware of it, so he is likely to spread the disease to others, fall sick and, depending on his health, die. If he recovers while being asymptomatic, no one could ever know the virus ‘exists’ in their village. If he died, no one would pick up on the unusual number of deaths in the village, but even if they did, they are unlikely to catch the attention of city-based government health workers.
Then there are those who fall critically ill, which often prompts turmoil in the family and the community, leading to decisions to seek help. As soon as this decision is made, it lays bare the dismal state of healthcare in the country. For all the clamour that elite Indians make about testing, it is a sad fact that physical distancing and testing don’t make comfortable bedmates. With the current state of healthcare facilities, one has to choose between testing and physical distancing.
If one has to test, one has to travel from one part of the state to a city. The patient, possibly accompanied by an attender, might typically only be able to afford crowded public transport, stay in a crowded lodge and enter a crowded hospital with a crowded lab. The patient thus becomes an agent of change – not of society but of the viral load of the people around him. Physical distancing in rural India is thus no more than a fantasy in the imagination of the elite.
Another thing that the lockdown is expected to do is buy time for a vaccine, even though that may take many months to realise. Even if a vaccine was available, it would be expensive and inadequate, and therefore available only to those who could afford it.
Lockdown and public health
A lockdown’s purpose is to flatten the curve. The question arises: If a lockdown hadn’t been in place, would the number of cases have gone up?? The answer is probably ‘yes’ or at best ‘not much’, but no one would want to take a chance.
The mortality prognosis for India would have been better if, in tandem with the lockdown, the government had raced against time to augment the healthcare system to handle a pandemic and resolve all the shameful systemic gaps thrown up by the infection’s spread. For example, even now, there are gaps in training of workers in comprehensive and ethical healthcare; supply chain and accessibility of drugs; regulatory mechanisms; a considerable need to increase healthcare budget and direct it towards public health facilities; and to nationalise private healthcare facilities so they can pull their weight during this crisis.
Of course, the incumbent government’s rise to power never included promises of public health, education, livelihood and employment. It is also important to understand who the policymakers currently are who is speaking on behalf of public health, farmers, nutrition, livelihood, children, Dalits, Adivasis, people with disabilities, transgender communities, women and the elderly? Sound policies are impossible sans experienced policymakers but sadly the idea that policymakers will make informed strategic decisions is a myth.
For example, India has been pursuing a campaign to privatise healthcare in the name of efficiency and cost-effectiveness. However, privatisation also breaks the socialist fabric of the country and has limited the ability of the country’s healthcare workers, labs, infrastructure, devices, emergency support systems, regulation, etc. to handle a public health crisis. This is not sound policy, and policymakers are not the ones ultimately responsible for what the government does – lawmakers are. And when people are not held accountable for bad policy decisions, they have no incentives to do anything other than what they think is best as determined by their political goals.
So will the Indian public health system be any more prepared for the pandemic (with or without a flattened curve) after an authoritarian lockdown? Can years of damage of public health systems be undone in 21 days? No. If anything, there are likely to be more illnesses for the system to deal with. A flattening of the COVID-19 curve may miss the rise in many other infectious and non-infectious diseases. Major programs like the NREGA, immunisation, institutional deliveries and nutritional programs will face major setbacks, but the state is unlikely to factor these issues in when the ‘success’ of the lockdown is measured.
A lockdown and its discontents
To a paid ‘work from home’ corporate employee, the government is not likely to say, “While we all stay indoors during this period of lockdown, let us also in the spirit of social solidarity receive equal salaries and pensions so that all of us are equally inconvenienced.” Nor is it like to ask them to eat only food provided by the government, irrespective of quantity, frequency and quality. Finally, would the government in the spirit of physical distancing order people from crowded housing and communities move into large mansions and bungalows so everyone has shelter?
If these conditions came to be, the middle class would simply refuse to participate in the lockdown, national interest be damned.
The rich in India are mostly happy to cooperate in a lockdown that inconveniences only the poor, and are more than ready to inconvenience domestic workers, auto drivers, delivery agents, construction workers, street vendors, etc. Viruses, however, have a way of sneaking up on everyone. All measures can only reduce the risk of infection, not eliminate it. The only way to protect oneself is to ensure that everyone else is also protected. A government that intends only to please the elite will ultimately be ineffective.
In attempting to protect (mostly elite) Indians from the virus, the poor have lost jobs, savings, their dignity, health, nutrition, education and their social security, while also bearing the brunt of abuse by police and the state.. We haven’t yet reached a stage where decisions are made primarily by those most likely to face the brunt of the lockdown.
Dr Sylvia Karpagam is a public health doctor and researcher based in Karnataka.