|Year : 2020 | Volume
| Issue : 3 | Page : 192-194
Lessons from COVID-19 in India: Extended lockdowns – At what cost?
Sachin Ramchandra Atre
Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||10-May-2020|
|Date of Decision||13-May-2020|
|Date of Acceptance||13-May-2020|
|Date of Web Publication||18-May-2020|
Ph.D Sachin Ramchandra Atre
Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Atre SR. Lessons from COVID-19 in India: Extended lockdowns – At what cost?. Med J DY Patil Vidyapeeth 2020;13:192-4
To prevent the spread of COVID-19 and prepare for the fight against it, India executed full country lockdown since March 24, 2020, and extended it until May 17, 2020. Such an extended lockdown is currently having a devastating impact on the large economy and poses numerous challenges such as poverty, hunger, unemployment, unwarranted migration of laborers, and other major health conditions that received low priority. This editorial discusses two different infectious disease scenarios – COVID-19 and tuberculosis (TB) – to make a case and provides an evidence-based perspective. It suggests a more reasonable strategy for current as well as future pandemics of respiratory viral infections in place of complete countrywide lockdown to prevent severe collateral damages and economic setbacks.
India with over 1.3 billion population is estimated to carry the highest global burden of both communicable and noncommunicable diseases. Since January 2020, COVID-19 – a viral disease – has started threatening the world, and several countries such as Italy, Spain, the UK, and the USA experienced its outbreaks. Those countries adapted lockdown as one of the stringent measures for containing COVID-19. The scare generated there was transferred to India through news channels, paper media, and social media which caused a negative impact that was described elsewhere. With India's weak public health system sustained on meagre 1.28% of gross domestic products  and large out-of-pocket expenditure in the private sector, Indian policymakers have multiple challenges for controlling COVID-19. As a precautionary measure, the government took an unprecedented step such as full country lockdown since March 24, 2020, and diverted major resources for its containment. Initially, the lockdown was declared until March 30, which was extended up to April 15, then to May 3, 2020, and now until May 17, with an uncertainty about further extension time. Against this backdrop, it is important to first analyze the problem and its scale in a holistic way, which, in turn, can help us to understand the cost of such lockdowns and guide on appropriate corrective measures. Here, two infectious disease scenarios: COVID-19 and TB – an infectious lead killer – are discussed to build a case.
Let us first look at COVID-19 status in India. As of May 9, 2020, there were 1.44 million tests carried out in India for detecting COVID-19 and of those, 59,661 (5.7%) were reported positive. Among 59,661, there were reported 1981 deaths., The case fatality rate (CFR) which is “the proportion of cases of a specified condition that are fatal within a specified time” was around 3.3%, which is consistent over a period of 1½ months. The CFR calculated per total cases is the least affected by reporting biases. Hence, it is used for calculation in this case. For COVID-19, the Government implemented an active case finding strategy, which requires considerable resources. Now referring to TB, as per the Global TB Report 2019, India notified 21, 55, 894 TB cases and 4, 49,700 deaths to the World Health Organization in 2018. Overall nearly 20% of notified TB cases had fatal outcomes. Since TB is a chronic disease with long and variable period from the onset of symptoms to fatal outcome, usefulness of CFR (which is generally used in case of acute infectious diseases) is limited. Nonetheless, understanding the gravity of TB from public health policy point of view in Indian context is highly relevant since the country carries a fourth of global burden of TB. For understanding purpose, if we consider average monthly burden of TB cases and deaths, that would be 1, 79,658 and 37,475 respectively. India's National TB Elimination Program implements a passive case finding strategy which involves low resource investment. If we compare data for both infectious disease conditions, it may be evident that despite implementing an active case finding strategy for COVID-19, the burden of TB and its fatality remains much higher than COVID-19. Furthermore, nearly 85% of COVID-19 cases have mild/no symptoms and they will not require any treatment, whereas all TB cases require an anti-TB treatment and many critically ill cases will require hospitalization as well. Thus TB requires significant financial and human resources. A rapid assessment by Stop TB partnership found that 40% of National TB Programs in 20 high TB burden countries including India (which is top ranked) reported that their resources (hospitals and dispensaries) are being utilized for COVID-19, and in future, if cases increase, all resources will be utilized. A recent report reveals that due to the disruption of the routine health system and priority for COVID-19, the diagnosis and treatment of TB would be greatly impacted. This might result in an estimated 20% additional deaths due to TB over the next 5 years. An important question arises – COVID-19 does not even justify its priority over TB – the single lead infectious killer in the country, how does it justify the entire country lockdown?
The low positivity in a high number of tested samples and consistent low CFR till date may possibly hint toward a likelihood that COVID-19 has a mild course in India, which may be comparable to several other health conditions. Furthermore, there is an evidence that COVID-19 is evolved naturally, so it may be reasonable to expect that a large number of people will eventually develop immunity through its exposure, which is anyway inevitable in a densely populated country like India. Nonetheless, it will take some death toll, especially among some immunocompromised individuals, which generally happens with any other disease condition. If COVID-19 has a very high virulence as being impressed upon by the media, policymakers, and some researchers, there would have been numerous seriously ill cases and deaths due to ongoing circulation since January 2020. However, there was no such report in the media from any part of the country.
Further, it is highly inappropriate to compare the data from European countries and America to that of India because there exist significant differences with reference to the scale of the population, poverty, climatic conditions, age pyramid, genetic makeup, lifestyle, food habits, comorbidities, pollution, and exposure to infectious diseases, etc. There is also a crucial role of government health policies and their execution, health system response, and population- and individual-level behavioral and social factors. These collectively determine the course of a particular disease condition in a particular country. For example, the TB incidence in many European countries and USA is around 10/100,000 and those countries are on the verge of TB elimination; however, it is still 199/100,000 for India and the prevalence is almost double the incidence. On the contrary, the situation of COVID-19 is different in India from those countries.
Although the available data support the assertion that the course of COVID-19 is milder in India than other severely affected countries, measures such as hastily implemented lockdown for COVID-19 control in this country having the second largest population in the world have major negative implications. A month-long lockdown in India is estimated to have economic losses of US $234.4 billion. Unwarranted hospital admissions and quarantine of thousands have resulted in an increased burden on the public health system and thereby increased exposure to infection for frontline health workers. Other health conditions are being neglected. Besides, there are other problems such as hunger, poverty, unemployment, and migration to hometowns in addition to psychological and financial problems for numerous people. A large number of people got stuck in different parts of the country and/abroad and faced various problems. The police system has been overstretched with day and night duties, and several reports of infections and even deaths have been reported among them. There would be many other disease conditions that currently go unreported in the population since the entire focus of the health system is diverted to only COVID-19. As per the latest World Bank Report, India has 175.8 million population with an income of $1.90/day/capita (International Poverty Line) and 659.8 million population with income US $3.2/day/capita (lower middle-income class poverty line). The lockdown in a country like India with such population composition has a devastating impact on the economy and also for the population. Such an impact will add to peoples' vulnerability to several infectious diseases including COVID-19 and can even change the course of disease any time which otherwise remained relatively mild.
Considering the above situational analysis, it would be proper for Indian policymakers and the government to deliberate on such issues before hastily implementing complete lockdowns in response to future pandemics of contagious respiratory diseases. A well-thought and planned execution of strategy can help to avoid the public distrust and confusion. The exit of lockdown should be done step wise by prioritizing essential services including the industrial production, agriculture, transportation, and attention to other health conditions that were sidelined. The last priority should be for businesses and places that involve crowding. Nevertheless, precautionary measures such as avoiding crowded places, physical distancing, obeying cough etiquettes, warranted use of masks by the hospital staff, caregivers, and symptomatic individuals rather than unjustified use by common people, careful mapping and monitoring of hotspot regions and high risk groups, monitoring of cases that approach the health system for hospitalization, etc., should be the essential strategies for control of COVID-19 and similar respiratory infections. The strategies such as active case finding and quarantine which unnecessarily cause stigmatization for infected individuals and their families in the locality where they reside should be discouraged as far as possible. The focus of resource allocation and utilization should be on cases that require hospitalization rather than asymptomatic positive cases. Unnecessary admissions of asymptomatic cases that can lead to overburdening of the health system and undue utilization of limited hospital resources with the potential of spread of nosocomial infection also need to be discouraged. The news channels and social media should have the responsibility of minimizing their role in spreading unjustified scare in the society. Considering India's health system structure where over 75% of households prefer private sector for minor or major illnesses, the utilization of private services would be essential to prevent the overburdening of the already weak public health system.
The lockdown experiment nevertheless has several positive implications as well. It helped in bringing a significant reduction in the air pollution, fuel consumption, electricity usage, and traffic. It thus helped in improving environmental conditions. It also showed a possibility of cost-effective strategies such as work from home for many corporate offices which may be considered in the long run. Finally, the lockdown clearly showed political will – the swift responses from the government to enforce regulations is not really a challenge, which public health professionals argued for years. The government and policymakers can take the cognizance of these above described positive aspects of lockdown and can plan steps to implement some of those in future. In all these activities, a coordinated response from central, state, and local level agencies is extremely important and expected to reduce the confusion among people. Depending on the epidemiology of future pandemics, lockdowns, if at all is considered an inevitable option, should learn from these lessons of COVID-19.
While a vaccine or a drug for respiratory viruses require rigorous clinical trials before we know their pros and cons, a strong immune system with healthy food and lifestyle as main pillars remains as the most important evidence-based natural remedy that has been helping us in defending infections similar to COVID-19 for years.
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