The lockdown imposed by the Narendra Modi government on 24 March to slow down the spread of the coronavirus outbreak in India left millions of poor and migrant labourers in the lurch. Unable to find work and earn money and in the absence of a way to reach home, thousands of workers decided to walk or cycle back home, with many dying of hunger, exhaustion or accidents on the way.
A policy that involves oppressing the poor through stringent lockdowns will adversely affect India’s battle against the novel coronavirus, said epidemiologist Dr Smarajit Jana, who is part of the expert committee set up by the NITI Aayog to help the government develop strategies to prevent and control the outbreak.
Jana, who heads the Sonagachi Research and Training Institute in Kolkata, has been credited with starting one of the most successful intervention programmes to stem the spread of HIV in India. In 1992, Jana led a team of medical professionals to work at Sonagachi, India’s largest red-light area, with sex workers, transgender people and economically backward sections of the society to help prevent AIDS. Jana also served as the national programme officer for the National AIDS Control Organization (NACO).
In an interview with HuffPost India, Jana, who, along with other experts of the panel, is helping ICMR with research on drugs, vaccines, testing strategies and kits for the COVID outbreak, explained why a lockdown is not a smart approach to fight COVID in India.
Edited excerpts from the interview:
Why, despite a stringent lockdown, have COVID-19 infections been increasing rapidly in India, rising by 10,000 cases in two days now?
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Let me explain that even the ICMR scientists who developed one sort of projection suggested that in our country, we can expect, at best, 50% flattening of the curve in a lockdown. If you compare with somewhere like the UK, where they have a partial lockdown with metros running, the success of a lockdown is about 80%. I also think the chance of a lockdown flattening the infection curve in India is less than 50%.
Application of lockdown varies across countries. Ours is one of the strictest, people have been asked to not leave their houses. That helps in social distancing and other behavioural changes like washing of hands, using masks when someone is going outside, sanitising of spaces. But it cannot be 100% successful in flattening the curve, keeping in view the high concentration of population in the country.
Even our last census shows that in metropolises like Mumbai, Delhi and Calcutta, around 50% people live in slums. In one room, four-five people are living. The same census said that 20% or more people live in the streets. So how will you lock down someone who has no house? Where will you lock him down?
Keeping that in mind, the projection said that if we have some success from the lockdown, at the maximum, it will be 50%.
So how will you lock down someone who has no house? Where will you lock him down?
The motive behind the efforts is not to reduce infections—you cannot stop the coronavirus infections. But measures are taken to plateau or flatten the peak so that the infections are spread over 7-8 months and the healthcare system is not overwhelmed.
You must get it clear that there was a wrong perception by many people that the infections will dramatically reduce this soon, we will defeat COVID or India will be COVID-free. The objective is to flatten the curve, so that there is no extra pressure on the healthcare system.
So it was concluded that through just the lockdown, the curve will be plateaued by 26%. But they also commented that if this is aided by adequate testing, followed by isolation of cases, contact tracing and quarantining of people actively, the curve could plateau by over 50%.
But that did not happen in India. For the country to acquire testing kits was also an issue, the testing was very low. So the reduction we can expect is by 26% only, it is their model I think. What findings we are observing, this increase of cases, it is likely to happen.
Since it is difficult to say definitively when infections are likely to peak in India, do you think the lockdown should be extended?
I don’t agree with the idea of a lockdown, for various reasons.
Basically, all these lockdowns were imposed based on the projections made by some scientists and their models. These models clearly said that we cannot achieve more than 26% flattening of the curve with this. We still don’t have enough testing kits with us, so it will be of little use.
Any sort of major change of this kind, when it is imposed from above, it loses its effectiveness as it is extended in time. For example, if you do a lockdown for a week, you can hope that a good percentage of people will obey the rules. But as you extend more and more, it will be less and less effective. So after two months of lockdown, if it is extended further, I believe the impact will be even less. On the other hand, it will affect the economy adversely, so you will have to balance between gains and the losses in taking a decision.
Let me explain a very simple thing. When we introduce a new medicine, there is a yardstick, we call that benefit-risk ratio. When the medicine is chosen, you have to determine what benefits it will provide and what are the risks involved. This is a standard procedure followed globally for any new medicine or medical process. Similarly, I would like to raise a point that when you are adopting a policy to deal with an epidemic, you need to do a similar benefit-risk ratio measurement. The more I go through, the less I find the importance of a lockdown.
It can’t be successfully applied to a country like India, where our population density is as high as 60,000-80,000 people per square mile
It can’t be successfully applied to a country like India, where our population density is as high as 60,000-80,000 people per square mile, in places like Calcutta, Delhi, Mumbai. All sorts of activities—markets, religious worship, transport—are accommodated in just that much space. Space is also a matter of privilege in India.
So, concentration of people is very high everywhere. If we have to bring a lockdown, we cannot do it the way it is done in the UK or the US. When you are applying an intervention strategy, you have to make sure it suits the demographic. If not, it will be ineffective. If the lockdown is extended further, it will not make any difference.
What is the alternative to a lockdown in India then?
This has a very simple and straightforward answer. As I have been working with dealing with the epidemic of HIV for the last 30 years. We have done one of the most successful interventions in India in the health sector that has brought down the number of infections drastically.
Both COVID and HIV have a similarity. To prevent both the diseases, you need to adopt a behaviour change in the communication pattern between people. In case of HIV, sexual behaviour of people needed to change. In case of COVID we need changes like keeping distance, washing hands, sanitising, wearing masks etc.
But we cannot change people’s behaviour with imposition from above, a body of authority. Nowhere in the world has anyone succeeded in changing people’s behaviour with brute force or imposing some legislation or law.
Nowhere in the world has anyone succeeded in changing people’s behaviour with brute force or imposing some legislation or law.
We knew even two months back that we have to live with COVID. If we have to live with COVID, what is the best way to live with it? The best way is to change people’s behaviour, which requires a scientific public health approach to involve community members. To help them understand and comprehend the illness and also help them face their social and structural barriers.
What we did with the most marginalised people — sex workers, transgender people, drug users — we helped them understand the problem and empowered them. We put them at the helm of the intervention programmes as peer educators, and volunteers. That made it a huge success.
We need a similar strategy to fight COVID — to involve people including the most marginalised, provide them the care and support they need to battle COVID and empower people around them, make them stakeholders. We have to come out of this top-down approach run by police and administrations. That may be effective for a short span of time in the early phases but if you go on extending it, it will have negative consequences. No one can challenge this — we need to change behaviour to fight COVID. This is a practical solution, any epidemiologist will agree with me on this. This over-dependence on the lockdown has to end.
A week or so ago, the NITI AYOG released an infographic which suggested that the COVID infections will dip dramatically in May and there would be no new infections after 16 May. As an epidemiologist who is part of the government task force, were you a part of this assessment or were you consulted?
My goodness, this is the first time I am hearing about this graph, from you.
(Laughs) This has not been discussed in any of the last few meetings. They were very pointed meetings on issues of research.
(Laughs again) I really cannot think of this. You see, the basic problem I find with these projects, when government or their agencies and fronts predict numbers on how many cases there would be with or without lockdowns, is their over-dependence on projection models.
Any epidemiologist in the world will tell you, models are made to fail basically. Models can provide some impression but it is never the gold standard. To develop a model, you start with some basic information and some assumptions. Those assumptions may not be true later on. More than the people making the models, it is a problem of people who interpret these as true. And don’t see the limitations of these.
(Later, when HuffPost India shared an image of the graph and a link to an article, Dr Jana commented that it was ‘hilarious’.)
Did the lockdown, due to which migrant workers were stuck in huge numbers in cities and shelters, aggravate the COVID problem? What should the government’s approach be on this?
There aren’t two responses to it, there is just one way. The government has to embrace them. In Bihar, 200 positive cases have been reported among migrant workers who live in poor conditions and reached home after long struggles. The way they were kept in shelters, or they lived and travelled, they were very vulnerable to contracting the disease. If they are really not included in the programme to fight COVID — not just as benefactors, but also members who implement the programme — we are going to lose the battle against COVID 19.
Now they are facing stigma and discimination. If they do not get to access healthcare properly, understand prevention measures, the numbers will swell drastically.
I can’t think how as a country we will fight COVID without taking them into confidence, or actively engaging with the poor migrant communities, I cannot think of running COVID intervention in India. You have to involve them in all possible tiers — in villages, at panchayat levels. This is a complex proposition, that’s why I think administrators love lockdowns. You just need police and others to make people not move around. But that won’t solve our problems.