The coronavirus pandemic has forced a large proportion of world population into domestic confinement – otherwise imperialistically termed as a ‘lockdown’. As on date, about 260 crore people in about 50 countries face legally imposed movement restrictions. While seven countries including Italy, France, UK, Poland, New Zealand, China, and India ordered a total lockdown, some countries like the Netherlands, Germany, and South Korea imposed partial restrictions on movement and gatherings. Sweden, on the other hand, only provided a public health advisory with no legal restrictions. Containing the spread of coronavirus due to human social interaction and thus avoiding crowding of hospitals is the principal motive of imposed lockdowns. However, containing social interaction adversely affects microeconomics and livelihood besides curtailing civil liberties.
Socio-economics distress is now apparent globally; including in resource-rich countries of Western Europe and the USA. Moreover, lockdown is not a recommended containment measure by the World Health Organization (WHO) or any other global public health organization. Experts and activists have stirred a debate on the effectiveness of lockdowns and its adverse humanitarian impacts. An open discussion on effectiveness is essential to democratically steer decisions leading to the removal of movement and social restrictions. To set a context for such discussions, this article analyses events leading to decisions of lockdowns containment of coronavirus infection.
On January 7th, 2020, China identified a new coronavirus as the causative agent of a respiratory illness epidemic affecting Wuhan. With previous experience of containing SARS caused by a coronavirus, China imposed general movement and travel restrictions in Wuhan. By mid-January, hospitals in Wuhan reported a dramatic increase in patients with respiratory symptoms followed by deaths due to pneumonia. With little knowledge of the virus and dynamics of spread, China was forced to increase movement restrictions culminating in a total lockdown of Wuhan on 23rd January 2020. China then took to aggressive testing of the population (using different clinical tools as laboratory testing was yet to be available) and prepared health care systems to manage severe cases. Diagnosed coronavirus infections (COVID) and deaths peaked by mid-February to only decrease sharply, thereafter. By mid-March, China was discussing the relaxing of lockdown norms in Wuhan due to a dramatic decrease in new cases. By this time, COVID was a pandemic, with several countries hosting multiple pockets of the outbreak. Governments across the globe were shaken and forced to look for quick solutions. Wuhan’s two-month lockdown and its apparent containment of COVID appeared as a solution template.
In the third week of February, COVID was an epidemic in South Korea, Iran, and Italy with all three countries imposing restrictions on public gatherings (including schools and events) and international travel. South Korea managed the epidemic with aggressive testing and isolation of positive cases, a containment template that Germany would later adopt. Unlike China, these countries were affected when the world had more knowledge about the virus and the time to organise testing infrastructure. But developing economies like Iran scrambled to mobilize health resources and were forced to depend on external aid. Thus, in the absence of aggressive testing, Iran took to impose restrictive lockdown in several of its cities.
In the first week of March, Chinese epidemiologists published details of transmission dynamics of the novel coronavirus, thus providing the world with an equation series – usable to predict the course of the epidemic in different populations. In quick time governments had prediction models for their countries at their disposal. Interestingly, Indian Epidemiologists of Indian Council of Medical Research (ICMR, Government of India) had modeled the course COVID epidemic in India, at least one week prior to the Chinese publications.
Simulation models, predicting infections, and deaths widely circulated in the media, with jargon like ‘exponential curves’, ‘infection peak’, ‘bending the curve’ being widely discussed. Meanwhile, in the second week of March, Italy witnessed a dramatic surge in cases that overwhelmed their health systems, resulting in 600-900 deaths daily. This surge of COVID cases was happening despite movement and gathering restrictions. Stories and videos of burdened ICUs, piling bodies, and long queues of coffins awaiting burials were circulated worldwide. Italy’s COVID spike stood testimony to the simulation models, which also predicted similar spikes in France, Spain, UK, and USA in the following weeks. Panic in the section of an informed population, across the globe, was palpable with public lobby groups pushing governments into radical action. Public discourse within countries was directed to avoid ‘an Italy like situation’, which eventually suggested drastic de-socialization measures. Lockdowns were a trending topic of action as China prepared to lift lockdown in Wuhan, citing successful containment. By Mid-March, Italy, Spain, the UK and some states of the USA had announced severe restriction of movements resembling a ‘lockdown’. The following week, a complete lockdown was legally imposed in India.
On 27th February 2020, ICMR’s medical journal received a mathematical simulation article from its own group of Epidemiologists. The article (which was later published in the third week of March) had simulated different scenarios of COVID outbreak and deaths in four Indian cities. Simulation models of cases and deaths were similar to the more publicised and discussed simulation model by the Maryland based ‘The Center For Disease Dynamics, Economics & Policy’ group. The article suggested several public health measures to tackle a bleak scenario of a widespread epidemic. Community engagement, surveillance, non-alarmist quarantine measures, prompt media reporting of facts were some measures suggested by the authors. The article did not advocate for restrictions of movement and social interactions or measures similar to that of lockdowns. The influence of this article on decision making in India (states and central governments), related to containment of COVID is not known.
The successive imposition of lockdowns in major countries was followed by lockdowns in smaller countries like Pakistan, Bangladesh, and Sri Lanka in Asia, Nigeria, South Africa, Rwanda, Libya in Africa, and countries of Latin America. However several social scientists and activists, worldwide, criticized the extreme restriction of people’s movement for a plethora of reasons. In Western European countries, the lockdown was also viewed as a curtailment of civil liberties and human right to socialise. Daily wage earners worried about job losses and eventual dependency on social security systems. Refugees and homeless suffered due to reduction is social support and decrease access to health care. In other parts of the world, issues were grave and related to food insecurity and loss of livelihoods. Activists predicted a larger humanitarian crisis in the developing world due to the unplanned and undemocratic imposition of restrictions. A consultative approach could have empowered communities to prepare for short-term distress. They doubted the capability of state machinery to ensure food supply and employment.
India witnessed immense distress among migrant workers and daily wage earners leading to sporadic protests. Many incidents of death due to migration were reported. The lockdown also reduced the efficiency of the health system in handling non-COVID illnesses. There are multiple reports of in-access to health care due to movement restrictions and denial of care due to fear of COVID. Vertical public health programs treating Tuberculosis, HIV, malaria, and care for sexual and gender-based violence muted their activity. The human cost of these restrictions is yet to be realised.
African countries face a graver situation of food insecurity due to lockdowns and sealing of borders. In sub-Saharan Africa, people stare at starvation even for a week of lockdown. In the Democratic Republic of Congo (DRC), people broke lockdown rules after one day of imposition. Currently, lockdown is only appreciable in the elite residential areas of their capital city. In the past too, lockdowns were not effective in containing Ebola outbreaks of 2014 in Liberia and Sierra Leone, despite military intervention. It is now well documented that community-based consultative plans helped contain Ebola in most remote of African communities including Sierra Leone and DRC. Public health activists continue to advocate a similar strategy to contain COVID in Africa.
Countries imposing lockdowns argue that the restriction of social interaction is essential to reduce deaths due to the sudden burdening of hospitals. In most affected countries, with the exception of Sweden and the Netherlands, the available hospital beds are less than predicted severe cases during the peak of the epidemic. Only a robust analysis at a later time (where more data is available) will indicate the effectiveness of lockdowns or otherwise. However, some preliminary data analysed by a group of US-based researchers suggest that countries with police enforced lockdowns did not save additional lives compared to countries that had limited restrictions (social distancing and ban on gatherings). Infection transmissibility did not change in Sweden, with no restrictions but reduced to a similar extent in countries with some restrictions like the Netherlands and in countries with lockdowns like France, Italy, and the UK. Likewise, in these countries, the total number of deaths was similar to those predicted by simulation models despite restrictions and lockdowns.
|Sl no.||Country||Total deaths on 24th April 2020 predicted by simulation before restrictions||Total observed deaths as on 24th April 2020|
Thomas Meunier and colleagues, Pre-publication manuscript, pending peer review; 1st May 2020
Initial trends of Western European countries and experiences of Ebola containment suggest that there was room for a less repressive alternate strategy to contain the COVID epidemic. On 24th March 2020, India recorded 74 new COVID cases with one death. On 6th May 2020, 42 days into lockdown, India recorded 3582 COVID cases and 91 deaths. Hence it is worth evaluating the effectiveness of Indian lockdown in preventing additional COVID related deaths. Given the high density of the population in urban India, a lockdown would have significantly reduced the transmissibility of coronavirus. But it remains to analyse if this gain translates into fewer deaths over time after accounting for humanitarian misery. As lockdowns are not sustainable in the long run, it is time to debate alternative democratic strategies that accommodate the livelihoods of the poor and limit the spread of COVID.