In light of health sector experts and experiences of other countries, the nation is taking a very important decision today,” Prime Minister Narendra Modi announced in a televised address to the Indian nation on March 24. “From midnight tonight onwards, the entire country, please listen carefully, the entire country shall go under complete lockdown.” For a full three weeks, no one would be permitted to step outside his or her home—a drastic and unprecedented imposition of isolation and quarantine on 1.3 billion people in a bid to contain the spread of COVID-19.
The authorities have since eased the curfew somewhat to permit people to buy food and other necessities. But can such draconian measures, copied in part from China, contain the pandemic in such a densely populated developing country as India? My decades of experience as a public health scientist living and working in Kolkata, a city with a population density of 63,000 per square mile, indicate that such a one-size-fits-all strategy, which lumps together communities with diverse occupations and living conditions, is likely to fail.
Yesterday, I walked past a bazaar frequented by slum residents, where perhaps a thousand people were buying and selling vegetables in an area of less than 600 square feet. More than 40 percent of the city’s population lives in slums, where three or four individuals share a single room with an average floor space of seven square feet. To them, social distancing or home quarantine can only feel like a cruel joke. In recent days, individuals in three slums in Mumbai, where living conditions are just as cramped, have tested positive for COVID-19. The virus could spread uncontrollably in these slums during the lockdown—inevitably escaping into the general population.
Many Indian cities also have extensive red-light districts. For example, more than 5,000 sex workers, whose profession heightens their risk of contracting and transmitting COVID-19, live in the Sonagachi area of north Kolkata. Curtains divide the single room that they and their families occupy into several sections, used for work, sleep, cooking and other activities. (At present, most sex workers in Sonagachi are not entertaining clients for fear of contracting the disease, but when they do, their children either play on the street or are cared for by retired sex workers.) If any of them becomes infected, how can they isolate themselves to protect family members and others? In addition, between 15 and 20 percent of the populations of Mumbai and Kolkata, including children, live on the streets and use public toilets with limited access to soap and water. How can they wash their hands repeatedly to avoid infection?
Just as worrisome is the plight of India’s migrant workers, who number around 50 million. The drastic lockdown brought the nation’s economy to a standstill and left millions of workers in the informal sector, who live hand-to-mouth in the best of times, without jobs or food. With virtually all transport halted, many began to return to their homes, often hundreds of miles away, in any way they could—even walking for days. Press reports indicate that hunger, thirst and exhaustion during this reverse migration have already killed at least 25. Eventually some state governments provided buses, into which the men and women crammed for journeys that would take hours. Some of them could well be infected with COVID-19, which they will likely transmit to other passengers—seeding the pandemic in pockets across rural India. Belatedly becoming aware of this possibility, diverse authorities have resorted to incarcerating returnees or even, on one occasion, spraying them with a disinfectant.
A frequent problem with public health interventions, including this one, is the real and enormous social distance between those who develop them and those they impact. Strategists often fail to consider the living conditions, occupations and other characteristics of the communities and individuals they are seeking to help. Such top-down, authoritarian measures cannot contain the spread of any infections in a nation with such high levels of poverty. Instead, public health authorities and civil society need to mobilize each community and enable it to work out its own strategy for self-protection.
Vulnerable groups such as slum dwellers, sex workers and migrant workers are fully capable of changing their behavior to fend off a novel threat to their health, as evinced by the success of HIV intervention programs in India. These are based on the so-called Sonagachi model, developed by sex workers and myself in the 1990s, in which those who are at greatest risk of infection participate in designing and implementing strategies to protect themselves. When last measured in 2017, the HIV transmission rates in Sonagachi, where a sex-workers’ collective called Durbar (meaning “unstoppable”) runs the ongoing effort to contain AIDS, were as low as 1.4 percent.
Durbar currently has more than 50,000 members in 48 branches across the state of West Bengal. In early March, I worked with Durbar’s health outreach personnel, many of whom are retired or part-time sex workers trained for the purpose, to raise awareness of the new danger. We advised sex workers to reject clients who had fever, cough or other symptoms of COVID-19; to bathe or at least wash up after each session; and to inform us if they developed any symptoms so that we could arrange for tests. Now that they can no longer earn, Durbar is crowdfunding to buy and distribute food grains so that the community does not starve, as well as soap, sanitizers and masks to fend off the coronavirus to the extent possible. Across India, ordinary citizens and non-governmental organizations are organizing similar relief and protection efforts for migrants and the urban poor.
We may have to live with COVID-19 and many more such viral illnesses for years to come. To survive them, Indians need to find the political will to redesign our public health system to serve the public—not to punish it.
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