Customise your pandemic responders
(Illustration: Saurabh Singh)
EACH COUNTRY NEEDS to plan out its own lockdown protocol. Measures that work in China, or South Korea, or New Zealand or elsewhere cannot be copy-pasted for use by any other government. This is not only ineffective in combating the pandemic physically, worse, it introduces a psychological deadweight; a sense of helplessness that inhibits recovery after lockdown.
No denying, of course, that hindsight is always very powerful, but have we learnt from plain sight? It is not forbidden to be aspirational and aim to be a South Korea or Germany, but a reaction to a pandemic requires quick, emergency action. The wannabe measures can wait for another day. They require gestational periods during which long standing institutionalised social features may need to be transformed, even radically removed.
Even as we scale down many of our lockdown guidelines, we must not go about it half-heartedly or with timorousness. If certain relaxations are allowed, then in all likelihood, they may not have been necessary in the first place. This is something that needs to be assessed, without partisanship.
Once we get that in perspective, getting out of lockdown can be an exercise in confidence. Some may still think that hardcore lockdown norms should continue. To address this concern, and many collateral ones, it is useful to examine how relevant the entire lockdown package was in the first place.
In order to get started on this we should not forget that when in an emergency, one must always begin by cognizing one’s immediate environment and acting on it. This kind of stocktaking must precede acceptance of remedial measure even if it comes from a reputed and credible source. Take it as if a vicious carnivore has attacked and you have no time now to raise it up as a vegetarian.
Confronted by Covid-19, what are the ground-level realities we need to cognize? Internationally, we have a basket of advice, all of which sensible, but not all of them are practical here in India. The jungle metaphor again. If you are told to climb a tree to escape a hyena pack, there should be a tree somewhere. It was Albert Camus, wasn’t it, who said that the truly absurd is when that which seems reasonable on one plane is totally impractical on another.
Let us then assess, one by one, the major public measures advocated to fight Covid-19, but not with political intent, rather as concerned citizens. As we go down the list, we will probably agree that when these measures were announced we did not know enough to come up with reliable alternatives. Over time, we now realise that our Covid-19 responses should have been more in tune with our realities and not so much an approximation of what other countries had done.
We must also self-consciously resist the temptation to overreach and craft policies that are too lofty as they would then be about as effective as school assembly moralisms. These, as we all know, not only leave the young unmoved but often tempt them to mischief. Likewise, our policies and recommendations to fight Covid-19 must stay in touch with reality or else they would breed cynicism. Should that happen, we might end up downgrading, in popular perception, even the meaningful suggestions.
First advice: Social Distancing. Can this work in India?
Internationally, we have a basket of advice, all of which sensible, but not all practical here in India. The jungle metaphor again. If you are told to climb a tree to escape a hyena pack, there should be a tree somewhere. It was Albert Camus, wasn’t it, who said that the truly absurd is when that which seems reasonable on one plane is totally impractical on another
No, it cannot. India’s structural morphology, or characteristics, do not allow for social distancing. In our country, every fifth urban person lives in a slum. Further, according to a report of the Ministry of Housing and Urban Poverty Alleviation, 70 per cent of slum dwellings have two tiny rooms, even less, and in which roughly 4.8 people live. To say they ‘live’ there may, perhaps, be an overstatement; they probably just sleep there. This conclusion is not unfounded because 44 per cent of these slum homes do not even have a kitchen.
A factor we overlook when we laud Kerala’s success in combating Covid-19 is that this state has a negligible slum population, only about 0.67 per cent. That Kerala has one of the lowest slum population figures in India makes it that much easier for its officials to control a pandemic. Where there are no slums, social distancing immediately gets a leg up. Of course, the Kerala government acted smartly in contact tracing when it faced a huge influx of overseas returnees. But if it had the slum population of the size Andhra Pradesh, Maharashtra or Tamil Nadu have, it may have been a somewhat different story.
For the same reason, Jammu & Kashmir, Uttarakhand, Puducherry, Mizoram and a few other states with less than 1 per cent slum population have had little difficulty in curbing Covid-19 infection. This, however, is not the typical Indian scenario. Slums proliferate all urban agglomerations in India, especially in newly emerging cities, though slums in metros get a lot of attention. Census figures tell us that while roughly 17 per cent of urban Indians live in slums, the figure is a high 27.2 per cent when we take into account small towns alone (‘Slums in India: Results from Census, 2011’ by Praveen Kumar, Journal of Environmental and Social Sciences, 2016).
In places like Mumbai, Faridabad, Meerut and Nagpur between 35 per cent to 45 per cent of the population lives in slums (‘Slum Population in India: Extent and Policy Response’ by Upinder Sawhney, International Journal of Research in Business and Social Science, 2013). This is why when we travel through nondescript urban places like Bahadurgarh, Lone, Visakhapatnam, Tirupur or Ghaziabad, we are assailed by the sight of slums. As we have been rather remiss in our town planning, we were blindsided by the need to set up industries in hitherto underdeveloped areas without paying attention to amenities (see ‘City Forgotten’ by Ayona Datta, Opendemocracy.net, September 18th, 2013). This is why small urban centres of more recent origin have such large slum sprawls.
Not surprising then, that we find surges of Covid-19 in such locales. Sources tell us that 11 cities (Mumbai, Thane, Pune in the lead) account for over 61 per cent of Covid-19 cases. Dharavi, India’s ‘maximum slum’, is merely 2.5 square km but has recorded above 3.5 per cent of all Covid-19 cases in Maharashtra. A large number of homes in this squalid sprawl are no more than 10 ft by 10 ft.
It is necessary to emphasise urban figures because pandemics have always spread from densely populated areas to distant villages. Every third Covid-19 patient is now in Maharashtra. That Maharashtra, Delhi and Tamil Nadu have so many cases of Covid-19 is also because so many of these new cities, soiled from the start, have come up in these states.
The 20th century Spanish flu did not fester in its initial stages in the countryside. The plague, after 15th century, moved from town to country, as well. This is because quarantine rules were being strictly imposed in many European docks which prompted sailors, tradesmen, prison escapees and mutineers, getting off ships in London or Venice, to run away to the hinterlands.
In trying to escape checks, they effectively took the plague with them and that is what made this disease a true pandemic. The way our migrants are going back from Maharashtra, Gujarat and elsewhere to their homes in rural Bihar and UP and, in that process, taking the virus with them is a historical replay of the past.
Given poor housing quality in India, it is obvious that social distancing is impossible for the poor to observe; in fact, a perfect case of Camusian absurdity. We seem to be doing the right thing, but, in the circumstances, so out of tune. The middle classes can practise social distancing with some degree of efficacy, but not the poor. Yet, the lockdown and the strictures that were imposed were meant for all and were never class-specific.
At the same time, it is not as if social distancing can be practised unproblematically among the privileged classes either. The white-collar executive and salariat will have to step out into common places from time to time. Those who run manufactories will perforce have to interact with poor people from slums who are in their employ, besides, of course, inhabiting contiguous work spaces. Water will gurgle in from outside and the boat will list, if not actually, sink.
In addition, it would do us good to remember that there is the driver, the doorman, the cleaning staff, the plumber, the electrician and the ubiquitous chowkidar. They are constant features, especially among those who take the trouble of being seriously cotton-woolled. The major reason for the lockdown was to make sure people did not comingle in close quarters at work. But as this is happening anyway in cramped homes, especially in slums, why separate the work place alone for harsh treatment?
The second advice: Wash hands regularly. This cannot work either. About 57 per cent of Indian slum households do not have access to tap drinking water. One of the reasons a cluster of dwellings is called a slum is because it lacks ordinary civic amenities like water and sewerage. Even when there is a tap, in the house or round the corner, it is important to factor in its utterly idiosyncratic dry and happy hours.
That municipality water does not flow round the clock is a common Indian experience. We must bear in mind that the only reason middle-class homes in India have 24-hour running water is because they all have overhead storage tanks. Constructing such tanks is out of the question in slums.
This makes it difficult to soap up froth in crevices around your fingers for 20 seconds at a time. Finally, as water is scarce, and taps at a distance, hand washing after every suspicious touch, or feel, is not practical. Washing hands seems like such a simple task but to make it work one will have to overhaul the city’s water system first. How did the World Health Organization overlook this when it sent out its advisory? This is an international organization which should have known better, as it has offices everywhere (‘Lack of Toilets and Safe Water in Health-Care Facilities’ by Jamie Bartram et al, Bulletin of the World Health Organization, 2015). Interestingly, the head of the WHO today came to political prominence in Ethiopia as an activist of a radical liberation front with strong Marxist leanings.
Further, slums not only have problems with running water, but most slum dwellers also have to share toilet facilities too. Dharavi, India’s. ‘maximum slum’, again demonstrates this ugly fact full front. The National Democratic Alliance regime has built a staggering 110 million toilets in India, but there are still many that are not fully functional because they lack water facilities (see ‘No Water in 60% Toilets Puts Question Mark over Modi Govt’s Swachh Bharat Mission’, May 14th, 2017, Hindustan Times).
In India there are two kinds of slums: notified and non-notified. In the latter, civic services, like piped water, are not assured, as in the former, yet 59 per cent of slums in India belong to this category. Kaula Bandar slum in Mumbai, for example, is a non-notified slum and suffers from a lack of water supply (‘The Right to Water in the Slums of Mumbai, India’ by Ramnath Subbaraman and Sharmila L Murthy, Bulletin of the World Health Organization, October 6th, 2015).
We should also bear in mind, 17 per cent of India’s villages still do not have drinking water (‘India’s Rural Have-Nots: Unconnected, without Drinking Water, Low Reading Ability’, Indiaspend.org, August 29th, 2018). If washing hands is then not always workable and yet we keep insisting it be done, this will arouse cynicism to this measure and put all the others in jeopardy as well.
Given poor housing, it is obvious that social distancing is impossible for the poor to observe; in fact, a perfect case of Camusian absurdity. We seem to be doing the right thing, but, in the circumstances, so out of tune. The middle classes can practise social distancing with some degree of efficacy, but not the poor
The third advice: Suspend public transport. This rule does not carry a proper rationale simply because social distancing is not happening at places where people live. By suspending public transport, it gets even harder for sick people to get to hospitals, especially those who are grievously ill and need medical attention.
Once the lockdown is lifted, public transport will start functioning again. That is all to the good, but certain steps need to be taken in advance. First, there has to be a powerful sanitiser dispenser at the entry point of a bus or metro carriage. For a few months, at least, there must be a transport official dedicated to making sure people sanitise their hands when they come in. Again, a question of habit formation.
In addition, crowding in public transport should be avoided and this means greater frequency of buses and metros. Instead of suspending, or curtailing, services of this kind, they should actually be expanded. To stop public transport was, to begin with, not a sound idea. Yes, temporarily, for a few days, perhaps, in order to position sanitisers and get more buses on the road, but not for so long. Think also of the psychological burden it imposes on those without motorised vehicles who are unable to help relations and friends in distress.
The fourth advice: Stop all schools. This measure was inescapable once the lockdown was imposed on March 24th, 2020. If movement outside home was disallowed, closing down schools would be a natural corollary. However, it is necessary to evaluate this factor separately, especially as we are now also plotting a post-lockdown recovery module.
As far as we can tell from the Indian data, the Covid-19 mortality rate for those between 0-15 years of age is actually negligible. Evidence also shows that if children above 10 get Covid-19 they recover remarkably well, without complications. In which case, middle and senior schools could have stayed open and functioned normally.
Even for younger children, there is no definitive evidence yet that Covid-19 creates serious setbacks, especially in Asian countries. Under these circumstances, when there is no actual and present danger manifested, opening schools should have figured high on the list once lockdown was eased (‘Covid-19 Symptoms, Outcomes in Children Decoded’, The Economic Times, April 23rd, 2020). Fortunately, indications are that schools will reopen early in the post-lockdown period and there is little reason to worry that this move may actually be quite premature.
However, as children could be carriers, they need to be wary at home, and certainly not as worried in schools. Covid-19 is not like a measles or whooping cough epidemic that specially attacks children. Perhaps, it is that image that made us extra protective towards the very young when planning our Covid-19 responses. We must also be sensitive to the fact that if schools are closed, without compelling reason, parents are inhibited from going to work. This impacts the household budget as well.
In which case, how should we deal with a pandemic? Once again, this set of advice stems from the experience of the past two months. In other words, there is no finger pointing here, either. Most importantly, the way out should be of the kind that allows for feasible practices at the everyday level which would also pump up self-confidence and psychological wellbeing.
We had no experience of a true pandemic in our lifetimes and we were naturally tempted by models and protocols coming from other countries. At that time, on March 24th, the country as a whole, regardless of political affiliations, was in a panic mode. Since then, experience has made us wiser and there have been several lockdown re-evaluations across the board. We must always keep uppermost the fact that there can be no recovery, in the true sense of the term, if people are going to stay scared.
In India we had a good opportunity in the beginning when we could have quarantined those who returned from overseas or who were hosting guests from other countries. In this particular pandemic, the middle class upward started the fire (see: ‘We Let the Rich Infect the Poor’ by the author, April 13th, 2020, The Tribune). The factories and workplaces could have been kept open and, instead, it is the executives who should have been screened.
It is the white-collared who should have been particularly mindful about social distancing and frequent hand washing when the disease first struck. Rather than doing that, in the early days, just prior to lockdown, it was workers and staff members lower in the pecking order who were thermo-checked at the entrance. In the meanwhile, the real carriers of Covid-19 virus, the middle-class professionals, were let in without scrutiny. That mistake is costing us dearly today and it was a pure class reflex.
We made this gigantic error because the privileged classes, from where decision-makers come, let their elite-oriented thinking go largely unchecked. This mindset flourishes not only at home, but also in offices, schools, marriage ceremonies, mall entries—everywhere. There is an unexamined assumption, amongst this section, that it is always the poor who carry dangerous diseases. If, however, we had eased up a little and looked at the matter from the other end, the lens would have blown up the image of the better-off and placed them under watch.
SO, THAT’S THE past. What now? How can we cross the lockdown Rubicon and stay confident inside our skins? For starters, let us plan what we can feasibly administer and proceed on information. Information flow is essential and we should be ready to respond if we feel the undertow too strong, or the pebbles slippery. The best way to test the depth of water is to do it one foot at a time.
1) Make masks and sanitisers mandatory: Masks and sanitizers should take over as our primary Covid-19 response, replacing the emphasis on hand washing and social distancing. Wearing masks should be made legal outside the home and advised for inter-generational households, within the home, as well.
Those found without a mask in the open or the streets or the workplace should be charged for being criminally negligent. In large organisations, fresh masks should be handed to employees every week. Incidentally, a study by the University of Washington has confirmed that masks reduce infections and should be worn as a matter of routine.
The emphasis on handwashing for 20 seconds is all right for those who have running water, but as that is not the case in most slums, provide sanitisers abundantly. These sanitisers should be given out to every worker as they enter the establishment and handed out freely in slums, on a regular basis. If some people misuse them, as some will, it is a small price to pay. Sanitisers are easy to use and easy to carry which makes them eminently appropriate as 24-hour companions and should, therefore, replace the 20-second handwash clips on TV channels. When it comes to sanitisers: ‘Don’t leave home without it!’
All factories, service centres, offices, buses and trains must have sanitisers and a specific operator who makes sure that each passenger uses them on entry. In factories and offices, two-hourly hand sanitisation should happen with compulsive regularity, under the supervision of a dedicated official. This top-down conducted sanitiser campaign should continue for a few months, till it becomes a habit, like it is for doctors.
2) Ban spitting: Next, make spitting illegal and ensure this law is implemented strictly. This would mean the closing down of paan shops, for obvious reasons. One can buy paan and betelnut to chew at home, but cannot spit in the open. Wearing a mask will inhibit spitting, but a law should be put in place to clamp down severely on this habit, especially in public places. An important accelerator in terminating spitting is if the middle classes and the well-to-do begin to see this practice as disgusting and stop indulging in it themselves.
As water is scarce, and taps at a distance, hand washing after every suspicious touch, or feel, is not practical. Washing hands seems like such a simple task but to make it work one will have to overhaul the city’s water system first. HOw did the WHO overlook this when it sent out its advisory?
3) Open all medical facilities: Hospitals should never shut down their OPDs nor discourage non-Covid-19 patients from turning up. Yes, there should be a special entry, exit and treatment zone for Covid-19 victims in all hospitals, but these institutions must be allowed to function normally. This is one case where ‘separate but equal’ actually works and is without prejudice.
The mortality numbers of non-Covid-19 patients shot up during lockdown because doctors scared everybody off by saying that the coronavirus was the single-most frightening enemy. This meant those who needed medical attention, but were not Covid-19-infected, stayed away from their doctors and suffered as a consequence (‘Deaths in New York City Are More than Double the Usual Total’, The New York Times, April 10th, 2020; ‘Shutdowns Kill People and Biz, Ease Them Fast’ by SA Aiyar, The Times of India, May 3rd, 2020).
Cancer and cardiac patients as well as those who depend on dialysis went through unnecessary hardship on this account. Fortunately, in many hospitals, doctors have now overruled this advisory, but it has not happened everywhere. Even so, doctors and hospital administrators should do a collective soul-searching to figure out how and why they had recommended such an incorrect advice in the first place. Doctor, heal thyself!
4) Train health workers: Simultaneously, we should train a large number of health workers, along ASHA lines, who will map the infected and contact trace those with whom the infected have been in touch. Quarantining should not be insisted upon, only advised to the extent possible.
Villages may now have to think of quarantine centres built out of MGNREGA funds but, in real terms, that won’t be very feasible. Instead ASHAs and PHCs should be energised to step out, intensify their rounds and advise how to minister to a sick person at home. Basically, it is about rest, paracetamols, fluids, masks and hand sanitisers. These aspects have to be reinforced.
Like it or not, quarantining stigmatises people and, sometime, the costs exceed the benefits. It also increases the chances of medical professionals being attacked by the public and, worse, concealment of the disease. By the way, India is not the only place where quarantining officials have been physically molested. This has happened recently in Africa and Latin America as well.
Historically too, as late as in the early 20th century US, quarantining officials were dressed up as soldiers to frighten people into obedience. At any rate, as we remarked earlier, quarantine works in states where there are no, or very few, slums, like Kerala. Even here, as Kerala’s Health Minister has observed, home quarantine is preferable, in the Indian context, to institutional quarantine.
Better still to caution people, in general about spitting, coughing and sneezing without covering their mouths. Health workers can also tell families how to take elementary precautions if there are elderly people at home. They must also advise those who are sick to stay indoors and not report for duty. In any case, this last aspect can be detected at the work place and the thermo scanning machine will turn such a person back.
These are measures which brook no compromise, or extenuating circumstances. But now let us consider a fifth suggestion which does not have the force of the first four.
5) Limit celebratory and religious gatherings: The fifth suggestion is to limit large gatherings whether religious or celebratory in nature. But this is a weak suggestion and it will work only if people voluntarily agree to do so.
There are, however, benefits that we could extract out of this pandemic. They are the following:
(a) Government will place greater emphasis in making sure clean running water is available in all dwellings, including in slums.
(b) The public will see the health advantages of using sanitisers regularly and washing hands, whenever possible.
(c) The practice of spitting will be seriously curtailed and with it the unhealthy practice of chewing paan.
(d) At long last, public health officials, ASHAs and PHC doctors will finally function as important medical gatekeepers. This is the push that was probably needed. It requires the administration to give health professionals closer to the ground greater incentives, respect and recognition. Together these might motivate them to work harder and be more connected.
(e) The stricture against large celebrations may even help to undermine age-old social evils like dowry, borrowing to celebrate weddings and wasting money in ostentatious functions.
If we were to do this, then coming out of a lockdown is a no-brainer. It is not as if we are advocating, as did Hebrew University in Israel, that there is no point in taking precautions at all (‘End All Restrictions, They Were Unnecessary, Hebrew University Researchers Say’, The Times of Israel, April 27th, 2020). At the same time, straightforward policies can be enacted that do not require soul-searching: statistical exercises, model building and other esoteric intellectual exercises. What recommends these also is the fact that these are eminently doable at the popular level. It is this feature that will help us come out of this very difficult phase without fear.
With some luck, the Covid-19 pandemic will soon leave our country. Hopefully, it will have left behind, unintentionally, of course, a positive legacy which will have cured us of many of our social mores and public inadequacies of the past. In which case, over the long term, this short-term setback might actually end up making us better citizens. Stranger things have happened. A crisis often clears up negative passages.