Coronavirus: India can’t fight Covid-19 if millions don’t know anything about it

At 5 pm on March 22, people across India poured out into the streets, banging on plates, blowing conch shells, chanting, “Go corona go”, “Bharat Mata Ki Jai” and other slogans. The revellers jostled together in large crowds, keeping significantly less than the prescribed one-metre distance between each other.

It was the crowning moment of the “janata curfew” called for by Prime Minister Narendra Modi, a 14-hour lockdown that was to be observed voluntarily by the public, to drive home the importance of staying in to contain the coronavirus epidemic. The clanging and clapping at 5 pm was meant to be done from balconies or windows. The idea, Modi had said, was to thank doctors and other essential services workers who did not have the option of staying in. But it turned into a sort of public exorcism of the coronavirus, with large gatherings that increased the risk of contagion.

In India, public responses to the pandemic have swung between vigilantism and a strange euphoria. This may stem from the fact that large sections of the public have no idea about how the virus spread or what they have to do to protect themselves from it.

The case for information

One of the foundations of an efficient public health system is a flow of clear, accessible information. “You have to keep people informed, let the community assess the risk,” said DVL Padma Priya, who worked on public health communications with Médecins Sans Frontières and is now the editor of Suno India. The government is already late to it. As contagion spread in China over the last three months, Priya ays, it should have kicked into action, spreading awareness about the virus and how to guard against it.

The government’s reticence has been explained by an “abundance of caution”, that it does not want to spread panic. It is a conceit that has to be abandoned, Priya said, because panic has already spread. As governments implement sweeping lockdown measures, it needs to explain the rationale behind them. Modi’s speech on March 24, announcing a three-week, nationwide lockdown, did dwell on the high infection rate of the coronavirus, but was vague on other details.

“The government needs to communicate uncertainty when it exists,” said Priya. “If you tell people there are things unknown, they accept that information more easily.” The recommendation is part of the World Health Organisation’s guidelines for risk communication during public health emergencies – build trust with affected communities, communicate uncertainty, tailor the message according to the needs of the community, engage local stakeholders.

Now is the time for the government to convey why it is important for people to stay home, maintain a physical distance from others and wash their hands. It is an effort that must be spread across Central and state governments. But, according to Priya, the Central government has the best machinery to ramp up public messaging at this point. While it has started a WhatsApp group called “MyGov Corona Helpdesk” to answer questions in Hindi and English, it seems to be a complicated interface, redirecting members to helpline numbers and an email address where questions may be answered.

Apart from the scarcity of information, the problem with public messaging on the coronavirus is one of language. The WHO guidelines recommend that risks should not be conveyed in technical language, as that would not sink in and change people’s habits, and that messages should promote specific preventive actions that people take.

As of now, the Ministry of Health and Family Welfare website has a link answering frequently asked questions. In stodgy, bureaucratic language, it outlines a brief summary of the symptoms, instructs people to “observe good personal hygiene”. The emphasis seems to be on travel – ask for masks if you feel ill on a flight, avoid non-essential travel to China. To the question of what the government is doing to contain the virus, it says a 24 hour helpline has been set up to answer questions.

Compare this to the advisory put out by United Kingdom’s National Health Service, which tells people to stay at home and what reasons might justify stepping out, details the symptoms, tells high-risk patients what to do, and breaks down preventive personal hygiene measures with the patience of a primary school teacher: “wash your hands with soap and water often”, “use hand sanitiser if soap and water are not available”, “cover your mouth and nose with a tissue or your sleeve (not your hands) when you cough or sneeze”.

Policing patients

It is not just bureaucratic-speak. As Priya points out, in several announcements and speeches, leaders have used “policing language”, not the language of public health. “One of the things that needs to come out is that the government cares for you, is there for you – it needs to be empathetic and transparent,” said Priya. Instead, there were announcements of officials having “nabbed” the suspected patient and taken them “into custody”, as if to criminalise those infected.

Chief ministers in many states have not done much better than the Centre. On March 7, Telangana chief minister K Chandrashekhar Rao called coronavirus patients “stupid” and “the cursed ones” when he spoke in the state assembly. It took the sudden surge in cases for Rao to change his tone and tell people to stay home.

The idea of disease as stigma has flowed from language into action. In states like West Bengal, Delhi, Punjab and Rajasthan, posters have gone up on the homes of potentially infected patients, saying “the home is under Quarantine, do not visit”. In Maharashtra, people placed under home quarantine were stamped on their left hand so that they could be identified if they went out. Jan Swasthya Abhiyan, a collective of public health activists, has written to Union Health Minister Harsh Vardhan to condemn the outing of potential patients without their consent.

“It is counterproductive,” said Amar Jesani, editor of the Indian Journal of Medical Ethics and a member of Jan Swasthya Abhiyan. “There are two aspects to this. One is utility – when people’s names are given out in public, it will contribute to their insecurities. If they wanted to self-report, they won’t now, so it won’t come out. The second issue is ethical. It endangers people as the government is not doing anything to provide security to people. These measures make them targets of community groups. You are creating social problems, violating human rights.”

The government’s words and actions have already encouraged community policing – in Telangana, landlords ask doctors to leave as they are “dirty” and could spread infection. In several parts of the country, airline crew and their families have been ostracised.

‘Break the chain’

In Kerala, which reported some of the earliest cases, had a head start in preparing for the approaching storm. A state government official speaking off the record said there were three major ways to contain a pandemic of this scale: “One, you let it take its natural course, but that takes lives. Two, you suppress it like in China, don’t bother about human rights. Three, you find the person, get his contacts, map his routes, ask everyone who came in contact with him to be home quarantined. This is very resource intensive and requires a lot of discipline.”

Across the country, 1,87,000 people are being watched for signs of infection. The government official said that Kerala alone had placed over 60,000 people in quarantine. These measures were also bolstered by an aggressive information campaign launched early on. The chief minister and health minister hold daily briefings and post alerts on social media. There is a helpline called “Disha”, to answer all your virus-related questions, from the serious to the banal.

There is a free Kerala government application, called GoK Direct, which posts regular updates and information about the symptoms of Covid-19, the number of cases, the route maps of those infected in the state. It is available in Malayalam, English, Bengali, Hindi, Tamil and Kannada. This ensures the information is legible to the Kannada speaking populations of the state, as well as to the many Bengali and Bihari migrant workers.

Early on, the state also launched a “Break the Chain” campaign to help contain the spread of the virus. “We focused on social distancing and hand washing,” said the government official, who has worked on the campaign. “We talked about human to human transmission – that you are the vector.”

Fifty celebrities were brought on board to relay the message. The government even created customised videos for each of them to post on social media.

Reaching the last person

But Kerala did not rely on electronic or social media alone. Newspapers and community radio were deployed. It also depended on mass participation. “Everyone has to own the the campaign,” said the government official. Every youth organisation and civil society organisation was roped in, as were panchayats and local governments.

“We thought of hoardings but if we wanted people to sit at home, we didn’t want them to come to public places to see them,” he said. Instead, hand washing was promoted to near-obsessive levels. Kiosks with wash basins or sanitisers were set up at government buildings and public places such as bus stands, and the public invited to “break the chain”. The elderly were advised to stay in and even if you visited them, you had to “break the chain” and go in, said the official.

In a country like India, these alternative means of communication are important if awareness is to percolate to the poorest and most vulnerable. Priya suggested using the old-fashioned loudspeaker tied to a vehicle, blaring out public service announcements. Faith or community leaders could also be roped in to relay the message. She spoke of the ebola outbreak in West Africa, where many were afraid to enter isolation tents. After healthcare workers went through church leaders, she said, public behaviour changed and more cases were reported. Governments in India also need to “demystify isolation wards”, she suggested, maybe by putting out pictures of the dreaded wards.

For now, however, India seems to have chosen suppression to contain the spread of Covid-19. From midnight on March 24, the country went under a strict lockdown. With its limited resources and vast population, India may have few options at the moment.

But the government should know that there is no substitute for accurate, accessible information on Covid-19. An anxious population kept indoors, with many worried about how to make ends meet in days to come, needs to know what it is that they are fighting.