The Covid-19 pandemic has imposed an unprecedented challenge to economies, governments, and health care systems. To date, as no efficacious vaccines or treatment are available (and are not expected in the near future), the principal strategy to control Covid-19 has focused on community-based social distancing measures (eg, lockdowns).
As a result, hundreds of millions of people worldwide have been given stay-at-home orders.
Lockdowns have been shown to be effective in reducing the speed of spread and to “flatten the epidemic curves” in countries such as China, Germany, Australia, and New Zealand. However, while these strict measures prevent the health care systems to be overwhelmed and reduce deaths, they also come with a significant cost.
When lockdowns go on for long, these stringent measures can have serious knock-on effects on employment, economy, mental wellbeing, and social order (especially in populations with limited social protection).
Epidemiological models showed that millions of lives could be lost worldwide if no intervention is taken. While in affluent settings (ie countries with superior economic resilience) the benefits of harsh lockdowns could outweigh the economic consequences, this net gain remains highly questionable in the low and middle-income countries.
Could a short-term remedy be far worse than the disease for low-income settings in the long-term?
To state the obvious, it is much harder to sustain lockdowns in a poor country compared to a rich one. In Bangladesh, for example, about 90% of workers are in the informal sector, and around a fifth of the entire population earn less than Tk500 ($6) per day. As a large proportion of the population relies on daily wages to support their families, a sustained lockdown will mean significant hardship to individuals and families.
This means that unemployment and hunger (ensuing from prolonged lockdowns) in developing countries could produce a number of deaths equivalent to those from an unmitigated epidemic scenario through social disruption, poverty, and starvation. A recent BIGD-PPRC survey in Bangladesh on 5,471 rural and urban slum households show that income has fallen on average by 70%, expenditure on food by 26%, and households can manage at best two weeks without any external assistance.
The effect is deep but also wide — more than 80% of the household whose income was above the national poverty line before Covid-19 now had below poverty level incomes. These are short term impacts which can change quickly depending on how fast and reliably the support from the government kicks in.
Disturbing scenes of social unrest and suffering globally are already emerging. Millions of migrant day-labourers were on the move in India defying lockdown to return to their rural homes, vendors rioted with police in Kenya, street fights erupted in South Africa and Nigeria over food shortages, and emergency food vans were vandalized in Bangladesh.
As calling a halt to economic activity can be disastrous, many countries are currently considering relaxing the effective suppression strategies to allow the economy to “breathe,” at least as intermittent measures.
However, there is a genuine risk involved: If countries lift the lockdown without a carefully-devised “exit plan,” there may be a major resurgence of the epidemic that could be just as bad as the first hit, if not even more catastrophic. The second wave of Spanish flu in early 20th century, for example, was far deadlier than the first wave.
So, how can a balance be reached between preventing deaths and preventing economic collapse?
More specifically, how can nations transform businesses when they re-open amidst an ongoing pandemic while keeping social distancing in place? What should the communities do in the time of coronavirus? What public health care measures should be put in place while Bangladesh and other developing countries target prevention and economic subsistence?
There are no easy or straightforward answers, and the involvement of all sectors will be key to generating the most suitable strategies.
As a way of starting the conversation, we propose here a 20-point exit strategy, which may serve as practicable, “locally-appropriate” measures, at levels of workplace, community, and health care.
At the level of the workplace
1) Educate, empower, and enforce all workers about the physical distancing and health/safety measures.
This should be a key shared responsibility of the employer to train all workers about essential aspects of optimal hand hygiene and physical distancing while at work. At the same time, the collective commitment is crucial, and the collective is as strong as its weakest link.
2) Adapt a wide use of nasal mask strategy.
Using masks (and, where possible, hand gloves) for all workers in all sectors should be achievable as these are low-cost interventions. Planning and preparation is essential, as well as education on the adequate use.
3) Restructure the physical environment of the factory.
Example measures could include, where appropriate:
– Signposting visual instructions on the walls and the markings on the floors to remind physical distancing
– Ensuring sufficient exit/entry points
– Regulating the worker “mobility” at the start or end of the shift so that the staff maintains safe inter-personnel distance
– Regulating the “access” to work areas by a“zoned in” approach (eg, prohibiting entrance into areas other than their own)
– Placing physical barriers between workstations to separate them, if feasible
– In high street shops, creating “one-way circuit” for the customers, not allowing more than a small number of customers at a time inside shops/restaurants, and setting up glass or Thai aluminum protective barriers at the cash counters.
4) Implement a flexible “shifting rotation” system for the workers.
In large worker-heavy but space-constrained factories, this staggered system could ensure a far less inter-personnel contact, reducing the risk of factory-wide spread substantially.
This, however, will also mean somewhat lower overall production of the factory, and some reduction in income for the workers. However, such a flexible system is superior to alternative scenarios where the entire factory is closed due to prolonged lockdown or a large number of staff being ill for not maintaining physical distancing adequately.
5) Ensure sufficient water, soap, and general sanitation facilities for all workers, including effective disinfection.
These measures for the workers, while they are at their shifts, will be crucial to ensuring personal protection.
6) Employ “health and safety” managers, if feasible.
These individuals can be specifically tasked to ensure that all above measures are appropriately implemented and sustained in the factories or business.
7) Create and enforce national standard operating procedures, describing bespoke measures that businesses must ensure in order to re-open.
This should be based on the above overarching principals. However, it needs to be tailored by specific industries.
At the level of the community
8) Shield the vulnerable and the elderly.
It is already established that older people and those with pre-existing conditions (heart disease, hypertension, and diabetes) are at the highest risk of adverse consequences of Covid-19. Therefore, protecting anyone over 60 and those with pre-existing conditions would be an essential task.
However, in South Asian contexts, where three generations live in the same household, it’s a rather complex task to effectively isolate the elderly. So one approach that could be adapted is to co-isolate another member of the house as the primary carer along with the elderly members. The members of the household, who work or study outside, must maintain physical distancing with those at higher risks at all times.
9) Wear nasal masks widely.
This should be done when outside, especially when within potentially “high viral-load” environments, such as public transports, supermarkets/bazars, hospital/clinics, and crowded offices (eg, banks or post offices). Within the household, members must wear a nasal mask if they have Covid-19-like symptoms or have tested positive.
10) Restrict mass gatherings.
These non-essential gatherings must continue to be restricted in order to prevent rapid acceleration of a subsequent epidemic wave. Such events include religious (Mosjid/Mondir-based or community-based), social (eg, weddings, sporting, movie theatres), and political gatherings, which involve over 50 people at one time. Appropriate social distancing restrictions should also put in place for public transport (eg, to leave empty seats in between).
11)Promote remote work, where possible.
These should continue to be done where they are safe and feasible (and has no knock-on effect on individual income, productivity, or hardship).
12) Run extensive community awareness campaigns.
These should continue to be done both at the national and local levels to ensure
– promotion of basic hygiene and sanitation practices to continue
– reducing social stigma
– risk communication
13) Maintain optimal health and immune function.
This should be done to successfully fight off the infection, especially people with underlying conditions. A healthy lifestyle is the key for a healthy outcome. A strong cardiorespiratory function and immune system can contribute to fend off the virus and its complications.
At the level of public health (care) system
14) Continue widespread testing, together with effective contact-tracing and isolation measures.
It is possible to achieve this by mobilizing a large number of community health assistants and/or through using digital platforms (such as bespoke apps or interactive text messages).
15) Implement a zoned lockdown approach (known as “cordon sanitaire”), when required.
This (India-style) hybrid lockdown, if required, should be applied to specific “hot spots” as they emerge to prevent sudden area-wide outbreaks/re-surge.
16) Establish epidemiological sero-surveillance in a representative national population sample.
This will be essential for public health action to a) keep a careful eye on the evolution of the new infections and b) quantify population-level immunity in order to track herd immunity status, and identify/prioritize vaccine targets once they are available. We recommend using a randomly-chosen nationally-representative subset of population for this national surveillance initiative.
17) Consider intermittent strict social distancing and relaxation period.
This is an interesting hybrid approach, where lockdowns and opening up economy happen as a specific schedule. This “switch-on, switch-off” measure can strike a right balance between protecting lives and reducing economic hardship. We are currently working on an international modelling study to determine the optimal frequency and duration of such “rolling” interventions for low-income settings.
18) Improve critical care infrastructure.
While economies open up, parallel efforts must be made to enhance the availability of the ICU beds, mechanical ventilators, personal protective equipment, as well as human capacities (eg, retraining doctors/nurses in critical care).
19) Create large (interim) hospital and diagnostic facilities dedicated to coronavirus care.
These need to be established at the district-to-division levels, based on re-purposing of existing facilities.
20) Promote public-private-people partnerships to achieve all of the above.
Bangladesh has been a shining example in solving many health problems successfully through public-private-people partnership of scaling innovative solutions (such as home based treatment of diarrhoea, reducing maternal and child health infections, and improving overall nutrition), enabling achievements of several MDGs. This is an important historic strength and must be harvested further for the current crisis.
As we continue to face a mostly unknown threat and have no specific guidelines on ideal exit plans (eg, from World Health Organization), it is, therefore, critical that developing countries formulate their own “context-specific” strategies before relaxing the nationwide social distancing interventions.
Besides solidarity, integrative thinking, multidisciplinary coordination, planning, and preparation are key.
Therefore, the measures proposed here might helpfully inform the policy-makers to think locally, act promptly, and balance health protection and economy pragmatically, in low-income settings worldwide , when a decision is made to relax the social distancing.
Dr Rajiv Chowdhury is Associate Professor in Global Health Epidemiology, University of Cambridge, UK. Dr Imran Matin is Executive Director, BRAC Institute of Global Development (BIGD), Bangladesh. Dr Oscar Franco is Director, Institute for Social and Preventive Medicine, University of Bern, Switzerland.
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