It is now obvious that the so-called lockdown imposed since last Monday was not well thought out. It has caused chaos and disruption disproportionate to any reduction in virus spread risks. The policy in place appears to be an ad hoc and strange mixture with exemptions morphing into the rules.
We are now beginning to see the rampage of Covid-19 in the developing world. The epicentre appears to be shifting to India. Bangladesh is racing to catch up. This wave is potentially more devastating than the first. The anxiety of the government to do something is therefore understandable. But it has been a bizarre tale.
What is the end game?
The whole idea is to get social distancing. But distancing also encompasses less drastic measures, like wearing face masks, staying out of elevators, limiting guests in weddings, avoiding crowds, staying in open air and so on. Diligent adherence to social distancing strategies is challenging. They must be imposed for the duration of the local epidemic and possibly until vaccination is completed.
Practices to reduce the chance of transmission (handwashing, maintaining 6 feet from infected people, etc) are recommended. There are many social gatherings that involve close contacts among people. Implementing measures to limit such contacts have seriously disruptive consequences too, but not nearly as much as "chaotic lockdowns".The latter is causing community disruption as well as loss of public trust in the government.
Communities faced with epidemics or other adverse events respond best and with the least anxiety when the normal social functioning is not unnecessarily disrupted. Strong political and public health leadership to provide reassurance and to ensure that needed medical care services are provided are critical elements. If either is seen to be on the short side, a manageable epidemic could turn into a catastrophe. This seems like a good description of everything that has happened since Monday – an idea without an endgame and eschewing any experienced-based evidence that it would achieve the goal.
What we are seeing is not a sacrifice for the "greater good". It is not a hard decision with arguments on both sides. It is not a risk-benefit scenario. The "risks" – loss of livelihoods –are turning into certainties, while the "benefits" – saving lives – are looking more and more like a mirage because of the chaos. When there is no social-safety net, you cannot tell people to stop working. Hunger, not disease, tops their worries and this worry is not limited to households with low incomes.
No time to waste time
Bangladesh remains vulnerable to subsequent waves for a longer period without vaccines. Time is what we want most, but what we use worst. This has proven painfully true with time being the scarcest yet most squandered resource in our response efforts. Lockdowns can be an effective pandemic response strategy that allow buying time but for what? We largely wasted the time during the lockdown in 2020. This did not bring us close to adequately scale up prevention, diagnostic, research, and treatment capacity.
We should adopt strategies to prevent and control the spread of Covid-19 in ways that are more responsive to local contexts. We should prioritise our limited resources, infrastructure, and personnel on supporting and sustaining a package of structural and behaviour-based interventions that will better prevent the need to re-introduce restrictive measures. Without due contextual consideration of their associated challenges and impacts, lockdown efforts only delay the long-term burdens to come.
When you do not have relatively robust healthcare system capacity, income support to allow people to make the choice to stay home, employment opportunities that allow people to work from home, and a telecommunications infrastructure that facilitates online education, lockdown measures risk leading to tragic consequences.
Follow the science
Successful pandemic response strategy requires more than a one-size-fits-all approach. However, follow the science is a prescription that fits all.
We know that to effectively slow and eliminate disease transmission, the connecting links in the chain of infection must be broken. The unprecedented nature and novelty of the virus is no excuse for ignoring science and the basics of infectious disease control and prevention. Instead, this principle in concert with the local epidemiological data and other contextual considerations should be used to inform response measures.
We have repeatedly seen within both high- and low-income countries the absolute centrality of governance and political decision-making as a determinant of pandemic response success. The deficit of trust between citizens and government as a result of corruption and inadequate investment in the health system means that the imposition of any response measures, especially coercive ones, is looked on with suspicion and derision. There is now an important opportunity for government officials to focus on community engagement and building trust through seeking to understand their unique contextual factors and using that information to tailor local strategies.
Increased engagement with communities can also create an opportunity to address issues of misinformation that is impeding vaccination, testing and care-seeking behaviour. Given that there is no silver bullet to address Covid-19, public policy decisions should target a combination of science-based and context-informed strategies that are the foundations of a strong public health system.
Get the basics right
Individuals can take certain precautions when they find themselves in the proximity of others, especially when in close quarters. Limit unnecessary contact with people outside your household, have get-togethers outdoors, maintain a safe distance from others, wear a mask that is effective at preventing the virus from being spread, avoid touching your face when out and about, and wash hands regularly.
Businesses have strong incentives to reduce the likelihood of transmission on their premises, both to protect their employees and to reassure customers. The "best practices" range from the use of PPE to cleaning of surfaces, use of physical barriers to imposing separation between individuals, where appropriate, and keeping distance between customers and employees as much as possible. Space tables in restaurants, stagger seating at small gatherings, introducing one-way aisles at grocery stores, and similar measures to curtail physical proximity.
While our understanding of the precise mechanisms by which the virus is transmitted remains inadequate, there is now reasonably good evidence that certain measures can reduce its spread. Most of these measures are things that individuals should wish to do voluntarily. But experience shows they do not do so without being nudged. This is not to suggest relying on the public to limit the peak of virus. There is a lack of actual published evidence showing that the nudge theory works in the context of coronavirus. However, subtle changes in the environment or context where decisions are made can only help.
The nudges can come from the government, private actors like shops or employers or even from ourselves. Painted lines or floor signs to mark distance between customers in supermarkets or elevators is one example. Another is to place a hand sanitiser container at the entrance of your home. We often take cues from how other people behave. Wearing a mask in public can become a new norm if this is what people see when they leave the house.
The recent protests by various groups suggest that it is neither feasible nor equitable to continue to police the details of our private lives through arbitrary and incoherent restrictions. Where appropriate, the government might seek to encourage businesses to adopt practices and standards. This will allow most businesses to maintain operation, albeit with additional precautions in place. More generally, the government should refrain from restrictions that limit the movements and economic activities of people at low risk with a system that encourages only those who are infected or likely infected to self-isolate. Those least likely to be infected should be able to continue working and more normal activities in relative safety.
The government, in partnership with the non-state actors, should develop systems to enable identifying clusters of Covid-19. These are really the classic epidemiological tools that have helped many countries. The actions must focus on steps to discover how widespread Covid-19 is in a jurisdiction, identify emerging virus hotspots or "clusters", contain those clusters and create data to understand the effects of behaviours and policies. Sharing information in an anonymised way through publicly accessible databases will enable individuals to manage their own risks. More data driven approaches based on testing and tracing are desirable.
Balance hope and worry
There is a need to carefully balance hope and worry in communication. Painting the situation too grimly risks fatalistic thinking. At the same time, we need to guard against the natural tendency towards overconfidence and optimism that gives people a false sense of security. Recent studies show that the young generation feel that the situation is not a major concern for them. Hopefully, now they know better. If people are not concerned, they do not act to address the problem. The trick is to give hope, but not too much to make people complacent, and make them worry, but not too much so they give up.
The aim of all these is to slow the spread of the virus and reduce the death toll. With luck, they will reduce the reproductive rate – that is the number of susceptible people infected by each person with the disease – sufficiently to restore confidence. Continued vigilance will be required for some time.
The timeline for widespread distribution of a vaccine is still an unknown. The recent World Bank estimate suggests vaccination to achieve herd immunity will take until at least 2022 at current rates. We need to accelerate vaccination to the best of our ability. There lies the hope above all worries.