Traversing the Pandemic in India- Is  ‘Physical Distancing’ covering the lost opportunity?

social distancing

There have been 15 flu pandemics in the last 500 years. Only those since 1890s have been restrained scientifically. The “Asian flu” of 1957 and the “Hong Kong flu” of 1968, were both encountered with modern tools of disease surveillance as compared to the 1918 Spanish Flu. There was no World Health Organization then, and efforts to track the outbreak of new diseases were extremely elementary.  The recent most Coronavirus, COVID-19 originated in Wuhan, China and spread globally in a short span of time of less than two months invoking the World Health Organisation (WHO) to pronounce it as pandemic on 30 January, the same day when India reports its first case. An interesting similarity is that the measures instituted to contain the outbreak at both the time points- 1918 and 2020, roughly 100 years apart, include ‘social distancing’ measures like isolation, quarantine, masks, hand-washing, staggering rush hour to reduce crowds in the public spaces and transport systems- despite the technological advancements which the medical sciences have achieved since then. Lockdown at the national level, however, did not appear as a measure at the earlier time point.

Changing Connotation of Lockdown

Interestingly, ‘lockdown’ has had a negative connotation associated with the mills and factories, consequent to which would be the retrenchment leading to joblessness, hunger and poverty- and of course the related issues ranging from morbidity to crime and violence. In my personal mental radar, the term found cognizance when our very own students were protesting against the fee hike and had resorted to it. Today ‘lockdown’ has progressed to attain a positive connotation to become a measure to fight the global pandemic that has descended on humanity! That is why, what started as a lockdown of 75 districts initially, spanned out as a national ‘janata curfew’ observed on 22 March, on the request of the Prime Minster, only to transform into the national lockdown as announced by him in his address to the nation at 8 pm on 24 March, ushering in the lockdown at midnight. While the other ‘midnight’ event which happened in 1947 on the fifteenth day of the eight month, gave us freedom, this one locked us down! It is noteworthy that since the outbreak of the novel coronavirus, on this day, when India took refuge in the lockdown, the world reported 375,498 confirmed cases and 16,362 deaths. The figures stood at 657 and 11 respectively for India- about 0.17% of global confirmed cases and 0.07% of global deaths due to COVID-19, despite the population size and density.

But the question which most of us want to seek an answer for, is whether complete lockdown was the only choice for containment of the pandemic. Perhaps yes, considering the poor public health infrastructure and pitiable PPE (Personal Protective Equipment) for the health care providers. In February the demand for PPE and other material for combating the menace of COVID-19 had become evident but no procurement regimen was put in place for many weeks to come. As early as 27 February, the WHO had issued the guidelines, noting, “The current global stockpile of PPE is insufficient, But it was only on 19 March, three weeks later,  that the Indian government issued a notification prohibiting the export of domestically manufactured PPE. This was a day after the PM had requested the country to applaud the health care providers by clapping and making sounds in the balconies.

The government’s decision-making process showed little urgency to address the approaching pandemic. The Directorate General of Foreign Trade, Department of Commerce, Ministry of Commerce and Industry,  issued a notification (No 44/2015-2020/31-01-2020) prohibiting the export of all PPE a day after we reported the firs confirmed case. But in on 8 February, the government amended that order (Notification No 47/2015-2020/8-02-2020), permitting the export of surgical masks and gloves of all kinds. On 25 February, by when number of confirmed cases had increased to three, without any death in India; and 80239 confirmed cases and 2700 deaths globally, the government further relaxed (Notification No 48/2015-2020/25-02-2020) the restrictions, allowing eight new items for export.  Despite the WHO recommendation for stocking the PPEs, required supplies were not requisitioned. Consequently, India’s doctors, nurses and subordinate ancillary staff have been exposed to the risk, as they continue to render services without adequate gears to keep them safe.

The poor public health infrastructure is evident by government’s own admission in the National Health Profile 2019, that its public spending on health was just 1.17 per cent of the GDP as is striving to increase it to more an 2.5%. Given the advent of COVID-19, there is no other way but to increase the share of health in the GDP.

Sapt-Shapath’ of  Lockdown-version2.0-  Mantra to combat COVID 19

Yet another address by the PM on 14 April, reflecting on the current situation in the country induced by the COVID-19 had a definite breath of fresh air for two reasons. One it was in the morning, and two, it included perceptible issues.  The nationwide lockdown imposed on the midnight of 24 March was further extended for another three weeks. This was advocated as the holistic and integrated approach to combat the crisis. The PM agreed that it was a harsh decision to take, but was necessary because the lives of the people was more important even at the cost of the dwindling economy. This perhaps is a strong message for us to take home, and to be implemented in the same fervor when it comes to lynching and killings based on social identity.

The COVID -19 tally had crossed the 10000 mark with more that 300 deaths on that day. Based on the consultation with the chief ministers of states, he firmly announced the extension of the lockdown till 3 May, 2020. Many states like Punjab, Odisha, Telangana and Maharashtra had already extended restrictions till the end of the month. He spoke of tangible measure to combat COVID-19 as compared to the earlier addresses which gave tasks to the people to engage with sound and light, albeit in a uniquely different way. In his characteristic modulated voice, he spoke of ‘seven vows’- which he proposed as the mantra against COVID-19. His charismatic style opened the address with an appreciation for the people for their adherence to the lockdown version1.0. Invoking the opening lines of the Preamble to the Constitution, he once again emphasized on the duties of the people instead of their rights. The state’s responsibility for ensuring healthy lives, safety and protection against diseases, were enveloped in the information pertaining to the improvement in the health infrastructure to the tune of  earmarking 600 hospitals for the treatment of COVID-19. In this enthusiasm, neglect of other diseases and illnesses; persons chronically ill, awaiting surgery,  those who have met with an accident, have died- all seems to have gone off the systems’ radar. No one seems to be getting affected by any illness or condition other than COVID 19. For instance, diarrhea continues to kill 2195 children every day. Most childhood cases of diarrhea are caused by rotavirus is evident from 2019 data source

The first of the ‘seven vows’ entailed a positive shift towards showing concern for the elderly from mere tasks of congregating in the balconies given earlier. The last ‘vow’, interestingly, reflected on the concern for the front line ‘yoddhas’ in the form of doctors. The other health care personnel like the nurses, ward boys and the subordinate staff like cleaners- of toilets and bedpans, those who change the beddings, work in the food and laundry units and engage in other ancillary activities, were conspicuously missing.  Remarkably, the Safai karmis were mentioned as ‘warriors’ for a change, perhaps for the first time- in any such rendition. However, in this list, a very important ‘yoddha’ who was missing is the one doing all the coverage and reporting of what is happening in these testing times. The media personnel have been toiling at the cost of their lives too, incessantly without fear, deserved an as emphatic mention.

The extended lockdown is designed to be more stringent. Any deviation from the guidelines will call for severe penalties and adherence  will earn some credits. At present, there is concern whether testing (of COVID -19 positivity) done, is of an adequate sample, of probable populations, and efficacy of different kinds of tests. Amidst such ambiguity, this kind of severity is likely to put the probable cases under the carpet, further contributing to the surreptitious spread.  Zoning of the districts and states under red, orange and green categories, based on severity of situation, is certainly a good administrative measure but such severity in punitive action may deter reporting. Occurrence of new cases will not be reported if the integrated approach proposes punishment instead of care provisioning. The cut-off time of 20 April for relaxing the lockdown if the ‘hotspots’ stop showing upward trends in confirmed cases and deaths; and no new hotspots evolve, the lockdown will be relaxed in those states. Those which fail on these counts will get no relaxation. Considering simple human psyche of desire to be praised, all state will vie for the former and cases are likely to be underreported and information suppressed. Another important aspect for the success of the lockdown could be more autonomy and financial support to states for executing their respective strategies for containing COVID -19, especially in the light of the zonation suggested.

On 20 April the number of confirmed cases reported was 17890 of which 8.5 % recover and 3.3% lost their lives. The share of deaths rose from 0.3% on 14 April. As promised, relaxation has been extended to conditional plying of private vehicles; 33-50% of employees can be called to workplace; essential services such as electricians plumbers and mechanics; all emergency services have been opened with adherence to safety guidelines.

Social Distance’ or infection detachment’?

Interestingly, the ‘social distance’ being advocated is actually physical distance that is needed. The term evolved during the 1918 ‘Spanish Flu’, which infected worldwide about 500 million persons and killed about 20-50 million people as documented in the pandemic history, the Pale Rider by Laura Spinney. Since social stratification of our kind is endemic to South Asia, the term appears appropriate for the nations who do not experience and practice it. In our case, it categorically has to be clearly stated as physical distance- keeping away from the infected, to differentiate from ‘social distance’ which we practice fairly much, given the graded inequalities. In this phase of lockdown, strict adherence to the safety guidelines, especially through ‘social distancing’ has been reiterated. But it no person affected with coronavirus is socially untouchable. The latter, however, may get affected with the former. The need is, therefore, to keep a safe distance from the affected so that the droplets cause due to coughing and sneezing do not reach the others. Hence, it is ‘physical distance’, or more appropriately ‘infection detachment’ – detached from the infected, one meter distance- that we need to observe to keep the virus at bay. We in India practice ‘social distancing’ fairly widely since long, and in a different context in which the phrase itself is high discriminatory. We are socially distant from, and critical of, each other on the basis of religion, caste, region, language, ethnicity, colour, age, residence, gender, economic status etc., despite the Constitutional safeguard professing the alternative.   Therefore, there is need to change the phrase. Even the World Health Organization (WHO) from 20 March 2020, has started to call it ‘physical distancing’ instead of ‘social distancing’. This term has been largely used by epidemiologists, to convey maintaining physical distance. Most of them situated in western hemisphere, are unaware of the social distancing which is practiced in the Indian sub-continent given the hierarchical structure of our society.

Resolve and Concerns-

It is noteworthy that while the doubling time of the confirmed cases has increased to eight, the number of cases has reached 23452 with 723 deaths and 4814 recoveries as of 24 April- four days into the second phase of the lockdown. The figures on 20 April were 17890 confirmed cases, 587 death and more than 1500 recoveries. Therefore, since then, the increase in confirmed cases has been 1.3 times, deaths have increased 1.2 times and recoveries have increase by 3.2 times. The improved health infrastructure, as announced, is perhaps attributing to this increase in recovery rate. But sadly we have no information of casualties,  happening due to other illnesses and accidents.

The law of exponential growth set in for India after it crossed the 50 cases mark on 10 March reporting 58 confirmed cases. It took four days to double, stacking the figures at 103, which doubled in six days on 20 March to 258. Further doubling happened in two days from 258 on 20 March to 403 on 22 March. Doubling periods has been fluctuating from 2 to 8 days.  But the progression does not happen this way. With increase in the number of infected persons the rate of transmission slows down and eventually the disease is eradicated. For coronavirus it has been estimated that when about 70% of the population gets the infection, then progression will automatically stop. Also, as reported, around 70-80% persons develop only cough and cold and get well on their own. Out of these about 25% do not even realize that they have any kind of contagion. Remaining infected persons need curative care. Those who develop pneumonia and respiratory ailments need critical care for survival (WHO, 2020). The elderly persons, especially those with co-morbidities are most vulnerable while children below age 10 have least risk. Therefore, given the dilapidated condition of our health care service provisioning,  and if most of infected persons are likely to get well without hospitalization,  and if the disease will spread despite all the efforts, then, what is the rationale behind the scare created for the disease? If lockdown has caused more concerns than contained the spread, how justified is the caution of ‘stay home-stay safe’,  shutting down all the outdoor activities? All the more when it is well known that the best prevention in the absence of a vaccine could be one’s own immunity, as that is what the virus attacks. Outdoor physical activities are known to build immunity.  Thus, it seem illogical to promote complete close down.

Thus, despite cases and deaths mounting, an end  to the restrictions awaits an insightful decision. While taking from the PM’s contention that health has to be secured over and above the economy, a leaf can be drawn from the American President’s tweet on March 23, 2020- ‘We cannot let the cure be worse than the problem itself…’ This is when the ‘lockdown was for 15 days and the quantum loss much more than ours. Therefore, it appears that lockdown could be a measure to partially address COVID-19, but not necessarily the best one- all the more when the infectivity of the virus is much higher and the fatality much lower, and the numbers in India remain much less than the other countries despite the population size and the density.

Sanghmitra S Acharya is Professor and Chairperson in the Centre of Social Medicine and Community Health, School of Social Sciences. Jawaharlal Nehru University, New Delhi. She was Director, Indian Institute of Dalit Studies, New Delhi, during 2015-18. She has been a Visiting Fellow at CASS, China (2012); Ball State University, USA (2008-09) and UPPI, Manila, The Philippines (2005); East West Center, Honolulu, Hawaii (2003) and University of Botswana (1995-96). She has travelled widely to other countries including Sri Lanka, Bangladesh, Nepal, Germany, The Netherlands, Belgium, The UK, Finland and Thailand. She was awarded Asian Scholarship Foundation fellowship in 2005. She has, chaired sessions, given keynote addresses and attended national and international conferences. She has published extensively in peer reviewed journals on the issues of health and social exclusion with focus on youth in development; gender in urban spaces; and North East India. Her current work is on social discrimination in health care access among persons engaging in cleaning occupations. She has five books and about thirty articles to her credit. Her publications include ‘Marginalization in Globalizing Delhi- Issues of Land, Labour and Health’; and Health, Safety and Wellbeing of Workers in the Informal Sector in India. published by Springer.



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