Featured image: A hospital in Kansas during the Spanish flu epidemic in 1918. Photo: Otis Historical Archives, National Museum of Health and Medicine
Do past policy interventions for diseases that swept the globe offer any insights to respond to the coronavirus pandemic currently raging across the world?
The closest historical example to our current situation, one that is commonly cited, is the 1918 flu pandemic. In the United States, cities used one of the following measures, or a mix of them, to contain the disease: notifying the flu as an epidemic; closing schools, churches, theatres, dance halls and public lodging places; banning public gatherings; and isolating sick persons.
In some cities, these non-pharmaceutical policy interventions (NPPIs) were put in place in the first days of an epidemic spread, while in other cases they were introduced late or not at all. Thus, there was great variance in the methods and timing of implementation measures in the US, and this gives clues to policy makers on the way ahead.
Let us start with a concrete example of the differential responses of the cities of Philadelphia and St. Louis. The first case of disease spread among citizens in Philadelphia was reported on September 17, 1918. The city’s officials did not take the outbreak seriously and continued to allow large gatherings, including a city-wide parade on September 28, 1918. School closures, bans on public meetings and other social distancing measures were not implemented up until October 3, 1918. By this time, the flu had already spread and was beyond the control of public health authorities.
St. Louis, on the other hand, responded with alacrity. The first signs of the disease were reported on October 5, 1918. The authorities implemented a wide series of interventions to promote social distancing from 7 October 1918.
The following graph shows the difference in death rates in the two cities. The difference in response times between the two cities was nearly 14 days and the epidemic was three to five times more severe in Philadelphia. The death rate at peak time was 250/lakh and 50/lakh in Philadelphia and St. Louis, respectively. The cumulative deaths (September 8 – December 28, 1918) were 719/lakh for Philadelphia and 347/lakh for St. Louis. The death rate in St. Louis climbed after the NPPIs were withdrawn in mid-November.
The response to the 1918 flu pandemic offers some lessons. First, aggressive social distancing, imposed early (i.e. when few people have died), leads to less deaths at the peak of the pandemic. Secondly, the number of NPPIs matter – cities where three of fewer NPPIs were implemented had an average per week death rate of 146/lakh as compared to cities implementing four or more NPPIs (65/lakh). Three, the interventions have to be withdrawn in a planned way otherwise the death rate will climb again.
Peak death rates were lower when large public gatherings were banned early, and schools, churches and theatres were closed. Early onset of the disease coupled with rapid NPPIs usually leads to an early response and reduces the peak death rate. Finally, the epidemic comes in waves, and cities with lower peak deaths in the first wave are more susceptible in the subsequent waves. Thus, a planned draw-down is required.
The Indian government’s social distancing idea enforced through the voluntary nationwide ‘janata curfew’ shows a deep insight into tackling the pandemic. It is the single-most appropriate response in a diverse nation with huge differences in health systems, where malls, cinema halls and streets are social areas and people traveling in buses (also trucks) or by rail and air are most likely to spread COVID-19 to other parts of the country.
Based on the learning from earlier experience, the Indian policy response should contain the following elements:
1. Continue the nationwide voluntary lockdown for at least for 14 days. During these 14 days, state/district/city-level plans for gradual draw-down should be formulated and implemented hereafter.
2. During the lockdown, design measures to continue work, which will also be useful for gradual withdrawal of NPPIs. Therefore, the present pandemic will be seen as a challenge to transmute the way we do things. For this, some principle may be established. The first principle could be to take services to people instead of people coming to the government and some examples include education (digital teaching), health and implementation of various beneficiary schemes.
3. The government can also start to deliver food to doorsteps instead of people coming to shops (e.g. ration shops).
4. For government offices, the principle should be to reduce their carbon footprint. This includes developing protocols for organising all meetings via tele- or video-conference mode. All file work and communication to be done digitally. Another principle could be trust people first and verify later. For this, there could be identify regulations, rules and practices where permissions could be automatic, within set timelines and field verification could be done later.
For the production sectors, announce an economic package, which protects incomes and employment.
These are only a few examples and several similar principles could be thought of and developed into policy instruments. All in all, a complete lockdown for some time with simultaneous measures that are transformative is likely to lead to an Indian way of dealing with the COVID-19 pandemic and bring about a permanent change in the way we do things in India and the world.
Sameer Sharma is a PhD from the USA and a DLitt from Kanchi University.