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Recently, we spoke with two panelists from our first COVID-19 webinar to answer some of your lingering questions about COVID-19 in South Asia — delving deeper into the impact of public messaging and the lockdown. Dr. Richard Cash is a Senior Lecturer on Global Health in the Department of Global Health and Population at Harvard T.H. Chan School of Public Health, and Dr. Srinath Reddy is President of the Public Health Foundation of India (PHFI).

Together, they explore improvements to future public messaging about the pandemic, as well as alternatives to lockdown and the social and economic costs of lockdown in South Asia.

How would you change public messaging [about the pandemic], including government bulletins? How can we improve messaging without stigmatizing the condition or invoking fear?

SRINATH REDDY: I am of the view that the repeated description of the pandemic as a frighteningly vicious mass killer, an avalanche of deaths, or similar terms, create a mass hysteria of fear and stigma. It is a viral illness from which most persons recover, and it needs to be projected as such. While our response has to be energetic and effective, our portrayal of the threat should not evoke panic or paranoia.

Should we stop talking of super-spreaders and patient-zeroes, when such stereotyping is harmful or of doubtful value in containing an epidemic?

RICHARD CASH: The use of the terms “super-spreaders” and “patient-zeroes” helps in trying to define the dynamics of an outbreak. The definitions are used in retrospect, as it is only after the epidemiology of a disease is worked out that these events or individuals can be identified. They are not meant to stigmatize persons or places.

What preventative measures, apart from lockdown, should South Asian countries use — such as increasing access to clean and running water in slums or free provision of masks and gloves? 

SRINATH REDDY: All of the measures mentioned are needed. I would even advocate shifting slum dwellers to vacant housing colonies and hotels where water supply and sanitation are more assured. This should be done at government expense. Permanent low income housing construction should be prioritized for their return from these temporary shelters. Nutrition and income security are also vital and should be ensured.

RICHARD CASH: There are a number of preventive measures, other than a national lockdown. The standard measures designed to reduce risk of infections are far less costly, effective, and more sustainable. These include the use of face masks, which should be widely available and free. India has the capacity to produce all that’s needed. They should be worn by anyone with clinical symptoms of a respiratory infection, anyone who has been exposed to a known case, and all caretakers of persons with suspected illness. They should also be worn in public — especially by those at greatest risk, the elderly, and those with some chronic conditions — and if the person is going to be in any type of gathering: religious, at the market, jobs where close physical contact is necessary. Many people wearing masks will reduce the stigma often connected with a single person wearing a mask. 

Handwashing is useful, but far more difficult to implement. If handwashing could become routine after going to the bathroom and before meals, this would be a great improvement. In India, namaste greetings are the norm, not handshakes. For widespread handwashing to be widely practiced, shortages of water, soap, and handwashing facilities in urban areas will have to be overcome. Face-touching is another risk factor, but difficult to mitigate. Coughing etiquette could be improved by spreading the message that people would cough into their arm rather than into the open. That some of these preventive measures are unlikely to be widely implemented shouldn’t prevent the messages from being disseminated. Multiple messages and approaches are usual in sensitizing the public. 

Some physical distancing could be achieved by limiting events, such as political rallies and large gatherings for sporting and religious events. Those living in slums or crowded village homes won’t be able to achieve much physical distancing, but will be made aware of its importance. Lastly, there’s a great need to improve the level, quality, and timing of communication from government, health experts, and the press (written, TV, etc.) on the true risks of Covid and the possible practices to reduce the risk of infection. 

Mixed messages have often been delivered, creating confusion and a disproportionate sense of fear. A heightened level of fear has led to an environment where the stigmatization of persons and groups has become all too common. Those identified as having COVID, health workers, and ethnic and religious minorities have been the victims of social and physical abuse by police and citizens. Fear has kept people who need care away from health centers, and [has prevented] health workers from conducting routine activities such as immunization, treatment of TB, and prenatal care. 

The longer the reduced coverage continues, the more lives will be lost — not to COVID-19, but to loss of routine prevention and care. Fear is also delaying the opening up of society. Overestimates of risk must be addressed through public health messages that are clear, concise, and doable.

How could low to middle-income countries like India mitigate the social and economic costs while enforcing lockdown? How do we protect vulnerable populations?

RICHARD CASH: It will be very difficult for any middle-income countries to mitigate all of the social and economic costs of an enforced national lockdown. The machinery of governments to provide food, health services, and income to its citizens is limited, especially in a country where almost 90% of workers survive on daily income, are not salaried, and worker’s compensation doesn’t exist as it does in richer countries. Quarantine of exposed persons or institutions is possible, but for a limited time only. National lockdowns are unlikely to impact the spread of SARS CoV2 in the long-term unless implemented for many months.

This strategy should be reconsidered when the population is vulnerable because of a loss of daily wages. The collateral damage from national lockdowns will increase over time and will likely contribute many more deaths than those caused by COVID-19.

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☆ All opinions expressed by our interview subjects are their own and do not reflect the views of the Mittal Institute and its staff.