As you read this, the COVID-19 pandemic is evolving. The science of epidemiology and health systems allows us to make reasoned decisions, anticipate what is likely to happen and importantly — what can help minimise the humanitarian dimensions of this public health crisis. The Indian count is rapidly increasing and critically close to the scenario of community transmission. What PM Modi did in his addresses to the nation on the 19 th and 24th March, was to sound the alert to minimise the impact in India.
As outlined by the WHO: the epidemic moves through stages: from imported cases to local transmission to community transmission to endemic phase. As new cases and epidemiological investigations unfold in India, The strategy to ‘flatten’ the peak of the initial graph of the epidemic has been by closing borders, quarantine, isolation, and ‘social distancing’. Social distancing as a public health measure is defined by the CDC, USA as "remaining out of congregate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible. .… and from ill persons with fever and respiratory symptoms.” This to keep a safe
‘physical distance’ that minimises the possibility of transmission. “Social distancing” is what the PM emphasised for all Indians, and the “Janata curfew” was an extraordinary communication and implementation strategy. Subsequently, the country was put under lockdown for 21 days, beginning 24 March midnight.
Social psychological evidence from previous epidemics shows that prescriptions such as of social distancing create fear of the infected and lead to increased levels of stigmatisation. Reports already tell us that a Mumbai elder who lost his life to COVID-19 and his family, among others, have suffered the experience of such stigmatisation, as have doctors, healthcare and airlines staff.
Perceptions of solidarity and caring need to be simultaneously mandated in concrete action.
The other well-advised steps, self-isolation for even mild symptoms and reporting to authorities for testing, wearing a mask in case of respiratory illness, are all to protect others; this is by way of social responsibility. When the message is specifically targeted at individual self-protection and narrow individual interest, and social responsibility is evoked only towards the nation without a word about the neighbour who may need help in such a crisis, it becomes an abstract notion. ‘Social distancing’ invocations lead people to ignore the normal ethics of social responsibility, that the well look after the ill, their physical and psychosocial needs, across social boundaries. On the contrary, it makes one look upon everyone else as potential infectors. This is further enhanced by the approach now being officially adopted across states, of publicly naming (and stigmatising) those in quarantine or infected. This is counter-productive for disease control since people with likely illness may avoid screening and testing for fear of such humiliation.
As routine activities get severely limited, communities have to be able to create resources and processes that enable their members to follow inconvenient rules and restrictions over unknown lengths of time. While lock downs ensure greater adherence to the physical distancing required to break the chain of infection, and mass drills such as a “Janata curfew” promote the required discipline, inconveniences and enforced restrictions are often evaded without the ‘community approach’ infusing the humanising touch and sense of solidarity,. The community approach requires ‘social bonding’, with mutual support groups being formed for people to help each other and find solutions collectively. For instance, to ensure that basic supplies are made available to those unable to move out, and to evolve leisure time activities that engage children and youth in keeping physical distance and yet facilitate social interaction. Social media and online resources are immensely helpful, but only if there is social bonding. Individuals shut down in their homes/rooms are not going to remain healthy for long. As evidenced in some of the worst affected hotspots, helplines are needed to support those in home-quarantine.
In any case, physical distancing is possible only for the better-off: not so for the nearly 4% homeless and 40% households of India living in one-room houses (Census 2011), or for the majority who cannot stay off work, in a country where over 90% are dependent on the informal sector for livelihoods. Putting migrants out of work and students out of their hostels has meant their travelling home in over-crowded trains and buses, which could easily have spread infections faster, and into the hinterland, than if they had been able to stay in the city where they were.
The shutdown inevitably disrupts economic activities and livelihoods that hit the poor first and the hardest. Appreciably, the PM urged all employers to ensure continued wages to their employees even without work. The poor with no savings, daily wagers who earn their bread daily, informal sector and contractual workers, vendors, and so on are all going to suffer loss of livelihoods with consequent increase in child malnutrition, adult destitution and starvation, rise in other diseases and deaths. Media ground reports are highlighting this fast emerging challenge. This has to be dealt with as social responsibility, with a sense of solidarity, irrespective of class, caste, religion, age, sex and
occupation; a structural social bonding.
Among a slew of actions for each transmission scenario, the WHO calls for a societal response: for “implement(ing) all-of-society resilience, repurpose(ing) government, business continuity, and community services plans”. Acting responsibly (for instance by self-isolating oneself) requires a supportive system in place that encourages members to do so. Even when the administration creates facilities, community support proves critical, for instance in ensuring supplies for daily needs reaching people, getting people to medical care; taking care of the elderly; protecting Livelihoods and wages of support staff; and so on. This entails community preparedness and a range of wholesome responses during times of physical distancing, such as organising volunteer groups in the neighbourhood, and creating conditions for people to de-stress, shed their anxieties and, assisting health care providers. While the government staff focuses on medical relief, care work and helplines the community level is critical as a layer in between the individual and the nation state, and preparation time for this too is now.
The WHO’s Strategic Response Plan recommends a series of actions that includes: “…, minimize social and economic impact through multisectoral partnerships. In specific, this Plan urges that “countries should coordinate communications with other response organizations and include the community in response operations”.
Focusing only on implementation of physical distancing and lockdown through visibly strong-arm tactics without sensitive consideration of the human needs in such a situation will hinder rather than help in effective control. Action plans on the rest of the elements need to be communicated in as clear terms. NITI Aayog, the government’s highest-ranking think tank is making a 100-day emergency plan to fight Covid-19; a media report quoting a government official lists the scope as: “assessing the need for manpower to personal protective equipment, ventilators, surveillance mechanisms, ambulance availability and various other things”.
Contrarily, ‘social distancing’ has emerged as a buzz word, an individualised behavioural term used for what is in reality ‘physical distancing’. ‘Societal response’ and ‘solidarity’ are not yet part of this epidemic’s discourse. Symbolic invocations create mass perceptions and therefore, along with acknowledging the medical and service providers, bonding with our fellow beings across caste, creed, class and religion must also get due attention. While maintaining physical distancing, social responsibility and social bonding have to be strengthened for this battle. It is to be hoped that the Niti Aayog and the National Task Force on COVID-19 will create strategies and processes that will support community action and include the community in formulating and operationalising response operations in a broad-based and inclusive manner. Only then shall we emerge stronger than before, as a people and as a nation.
Ritu Priya and Rajib Dasgupta are medical doctors and public health Professors at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University
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