Coronavirus Outbreak: How effectively will policies of travel restrictions and social distancing control the spread?

In the second of a four-part explainer on the coronavirus pandemic, Mridula Ramesh writes: if we spread to Stage 4, where we have epidemic local transmission of COVID-19, hospital capacities would soon be overwhelmed, which may leave millions dead. Which is why policy action has been aimed at ‘flattening the curve’ or spreading out the infection trajectory to allow hospitals to cope.

Mridula Ramesh March 23, 2020 09:12:02 IST
Coronavirus Outbreak: How effectively will policies of travel restrictions and social distancing control the spread?

This is part 2 of an explainer on the coronavirus pandemic. In part 1, where did it come from? How does it spread? Who and how does it kill? What might stop it?

***

What are the implications of this on policy?

Pray for summer, obviously. But, what else?

Any policy has to be mindful of the virus, and of the capacity of the country.

Let us compare the treatment capability of different countries affected with India’s. This is data from the WHO, accessed through the World Bank.

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Clearly, if we spread to Stage 4, where we have epidemic local transmission of COVID-19 , hospital capacities would soon be overwhelmed, which may leave millions dead. Which is why policy action has been aimed at ‘flattening the curve’ or spreading out the infection trajectory to allow hospitals to cope.

What has/can be done to prevent this?

Travel restrictions

The virus originated outside India. India reported its first confirmed COVID-19 case on 30 January 2020. Predictably, Kerala was the state who confirmed the case, given their excellent medical tracking abilities. The patient was a student who had been studying in Wuhan and returned to her home in Thrissur. In an interview, she is reported to have said,

We left Wuhan by train to Kunming, took the flight to Kolkata and then to Kochi on 24 January. I had a phone message from the Indian embassy to report to the nearest medical hospital on arrival at Kochi airport, which I did. They took our temperatures and again there was no sign of any infection… I arrived in my village in Thrissur, I was careful to impose self-quarantine at home…On 27 January, I had a sore throat and cough for the first time and I immediately alerted the authorities and was asked to go the General Hospital in Thrissur. When I went there, I still did not have temperature and they started me on antibiotics… The result came in positive on 30 January, nearly a week after I left Wuhan.”

There were hundreds of Indian students studying in Wuhan. While others were later evacuated by the Indian government and quarantined, the first wave that came on their own presented a wider infection risk. While states like Kerala, with an excellent medical system, tracked and monitored the cases, what about those who returned to states with creakier infrastructure?

Within days of the first positive case being announced, the Indian government had announced a travel advisory, asking citizens to refrain from travelling to China, and saying anyone with a travel history to China from 15 January could be quarantined. They also stopped/cancelled visa facilities for Chinese nationals.

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File Photo. AFP via Getty Images

Italy also received its first COVID-19 courtesy Wuhan — in this case a Chinese couple who arrived from Wuhan on 23 January, and travelling through Italy. The Italian government sealed off the hotel, and suspended flights. Interestingly, on 31 January, the BBC reported the chief of the WHO, Tedros Adhanom Ghebreyesus, as saying, ‘there was no reason to limit trade or travel to China’.

Travel within India had not slowed. I was at a set of meetings in Delhi in early February. In the airport, only a handful of us were wearing masks. The pharmacy in the Delhi airport was still selling hand sanitisers at the regular price, though they did try to push the more expensive one first. The virus also spreads through the oral-faecal route. Given that so much of India’s drinking water is contaminated, this is of particular concern. If you want to look at it another way, this might help facilitate herd immunity.

For a while it seemed the virus might be contained. China had battened down the hatches, and was weathering the COVID-storm. The number of new cases globally was slowing down. The world heaved a sigh of relief. US President Donald Trump tweeted ‘The coronavirus is very much under control in the USA. … Stock market starting to look very good to me’

Meanwhile, in Italy, Iran and South Korea, the next phase of the epidemic was beginning.

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In early March, the Indian government issued another travel advisory asking Indian citizens to refrain from travelling to Italy, Iran, South Korea and Japan, and suspending visas for citizens of those countries. In addition, all returning travellers would have to get a certificate of being COVID-free and self-declare that they were well. All travellers would be screened at the airport. Travel within India was still going on, but with some fear.

All around the world, travel restrictions were going up, and countries were sealing their borders. Even the Islamic State (ISIS) warned its terrorists not to enter Europe!

By 10 March, internal travel started to slow down, as the number of positive cases many of those either immediately returning from abroad or their family members/persons in close contact, began to ratchet upward.

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There is a nifty little dashboard on COVID-19 timelines, which I would encourage you to check out. By taking the data from this dashboard week wise in March, I came up with this:

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Clearly, the virus was being transmitted locally, through contacts with those that returned from foreign countries – Italy, the UK and the Middle East (Saudi Arabia, Iran and the UAE). The latest case, reported in Tamil Nadu, was different. This was 20-year old man who travelled by train from Delhi to Tamil Nadu, and as far as is known now, had not travelled abroad or come into contact with any foreign-returned person. Was this community transmission? It is far too early to say, especially given the low level of testing in India.

On 18 March, India banned passengers from Europe, the UK, Turkey, Afghanistan, Malaysia and the Philippines from entering the country. Furthermore, passengers who had travelled from COVID-19 hotspots, including Italy, from 15 February, would be quarantined for 14 days.

Passengers from UAE, Qatar, Oman and Kuwait would be placed under compulsory quarantine.

From the night of 22 March, India will shut off from the world. No commercial aircraft from a foreign country will be allowed to land in any Indian airport.

If implemented well, this could have a good effect. However, there are, how shall I put this politely, morons in our midst.

The Bengaluru newlywed techie’s wife’s story appears to have shades of grey, so let us leave that be. There is also the case of the Bengali bureaucrat’s son. Or the case of B-town singer, with some reporting that she hid in the bathroom to escape airport screening. It is confirmed that she was at parties with Members of Parliaments and senior politicians, putting the leadership of the country at risk. All three claim they were asymptomatic when they passed through airport screening.

The problem with self-declarations, even if people are truthful, and airport screenings is this: a significant number (between 17-30 percent) of people infected with the SARS-CoV-2 are asymptomatic. They have no fever, no cough, no sore throat. But they are infectious. They pass through every screen, and go on to infect those who may be less fortunate.

Imperfect as travel restrictions are, they are effective, and may have very well prevented from a full blown epidemic in India until now, when the temperatures are rising.

However, at the other end of the spectrum we have outright mal-intent. One example of this, are the kids partying in the beaches of Florida, who, on TV, say they don’t care about the coronavirus . Then there are those in India, who with full comprehension, of risks, take them anyway. Which is why we come to social distancing. Since anyone can have it, better to play it safe. The Prime Minister’s address to the nation on the 19 March said as much.

Social Distancing

Most countries are focussing on prevention, which in turn focusses on minimising the virus load transmitted from one person to another. At the centre of this effort is social distancing. In social distancing, we keep away from others, preferably at greater than one-metre distances, for as long as we can. The hope here is that by doing so we break the chain of spread of the virus.

Is it safe though? Is it realistic?

The virus is a tableau of unfairness. Those who brought it to India have enough money to travel by plane outside the country. This is a tiny fraction of India’s full population, many of whom have not travelled far away from their place of birth. Much of India is employed outside the formal sector, with their hands, where work-from-home is a cruel joke. Shutdowns affect those who, for no fault of their own, are impacted. I’m not saying shutdowns are a bad idea, but they come with a cost on those who cannot bear it.

Importantly, is social distancing realistic?

I recently walked through a part of Dharavi, one of the largest slums in Asia, which is a popular destination in the ‘poverty-tourism’ circuit. Houses, 8 feet by 5 feet, hold entire families while being stacked next and atop of other such houses. I was told that 70 percent, more than two-thirds, of Dharavi’s one million population relieves themselves in community toilets. During our walk, we did walk past two of these community toilets. They looked reasonably well maintained and had lines of men waiting, face down, lota in hand, for their turn.

Can we really believe that social-distancing is anything but a forlorn hope?

Where other options do we have? Shut down, test everyone, or weather the storm and hope for herd immunity. Let us consider each of them in turn next time.

The writer is the founder of the Sundaram Climate Institute, cleantech angel investor and author of The Climate Solution — India's Climate Crisis and What We Can Do About It published by Hachette. Follow her work on her website; on Twitter; or write to her at cc@climaction.net.

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