As India faces the most dire crisis experienced by any country since the start of the Covid-19 pandemic, the media has placed a spotlight on dying people being turned away from hospitals, patients running out of oxygen, and crematoriums on overdrive.

In the face of these heart-wrenching reports, healthcare workers and the Indian public have scrambled to mobilise resources to help individuals affected by Covid-19. Most of these efforts have understandably focused on short-term requirements such as improving access to make-shift hospital beds, oxygen tanks, and therapeutics, or on advancing India’s vaccination campaign.

While therapies and vaccinations are crucial, addressing medical needs alone is inadequate given the severity of the current crisis. India cannot treat or vaccinate its way out of this surge without great loss of life. Given the near-collapse of its health system, India must urgently consider a nationwide shelter-at-home recommendation. A nationwide shelter-at-home recommendation could avert numerous deaths, while buying time to advance India’s vaccination campaign, which is the path out of this pandemic.

However, any such directive must be implemented in a humane manner that avoids the mistakes of its nationwide lockdown last year. We therefore avoid using the term “lockdown” here – a term that evokes painful memories for millions – to emphasize that future social distancing measures should use a different approach.

Flattening the curve

The most urgent reason for a shelter-at-home recommendation is to stop further deterioration of India’s healthcare infrastructure. Early in the pandemic, the concept of flattening the curve – using social distancing to keep Covid-19 cases within the “ceiling” of hospital capacity – gained widespread currency.

With limited knowledge of effective therapies and no vaccine in sight, shelter-at-home recommendations were widely recognised as the main public health measure that could rapidly curb transmission to allow health systems to cope.

Before the pandemic, India already ranked 155 out of 167 countries in hospital bed capacity per population. The current lack of oxygen supplies and beds suggests that the ceiling of hospital capacity in much of the country has been shattered, impeding care not just for patients with Covid-19 but for those with other life-threatening illnesses as well.

In addition, the few Covid-19 therapies that are known to benefit individual patients, such as dexamethasone, provide only small reductions in the death rate for the overall population.

Cohesive nationwide social distancing measures are also critical to contain the spread – within and across Indian states – of newly emerging variants that may transmit more easily and potentially explain the current surge, such as the B.1.1.7 “UK” variant in Delhi and the B.1.617 variant in Maharashtra state.

While vaccines are effective at preventing severe disease and death, in a country of nearly 1.4 billion people, even the most efficient vaccination campaign would move too slowly to make a dent in the current emergency. At present, less than 9% of the Indian population has received one vaccine dose and about 1.7% of people have been fully vaccinated.

The pace of vaccination in India has slowed markedly in the current surge, but even optimistically assuming the previous rate of about 3.5 million vaccine doses administered each day, only a small percentage of India’s overall population (about 7%) would receive any vaccine dose in the next four weeks.

Moreover, protective immunity does not transpire overnight. It takes about two weeks to achieve moderate immunity from one vaccine dose. Since second vaccine doses are given four or more weeks later, the small number of individuals vaccinated today would only achieve maximal immunity a couple of months from now, conferring a negligible increase in immunity for the overall population. With current Covid-19 case rates of 350,000 new cases per day, countless deaths could occur during this time.

Mixed signals

Currently, shelter-at-home measures in India have only been instituted locally by state or city governments. We would argue that these local measures are sending mixed signals to Indians and are insufficient to curb the current surge. Some states have instituted partial or full shelter-at-home measures that are highly variable, including night curfews, weekend shelter-at-home orders, and travel restrictions of variable duration. Others continue to host election rallies, religious festivals, or sporting events.

While targeted social distancing measures have been shown to reduce economic losses while curtailing localised epidemics, the current surge is unique in that every Indian state is witnessing a rapid uptick in the seven-day moving average of new cases; the inter-city, district, and state boundaries are also porous.

While the current case numbers vary considerably, what is remarkable is that the rates of rise in most states mirror those in the hardest hit regions, such as Delhi and Maharashtra. In our opinion, the slope of this rise is the most important indicator of where the pandemic is heading. In other words, Delhi and Maharashtra possibly portend the future for states that seem to have low case counts right now, which is why state-level shelter-at-home measures are not adequate.

As we have seen from other places in the world, without social distancing measures, Covid-19 can increase exponentially, so these locations may be only days to weeks behind. Even more concerningly, the most rapid growth in cases has occurred in some of the large states with predominantly rural populations. About 800 million Indians live in rural areas, where Covid-19 testing and hospital bed capacity are considerably weaker than in urban areas.

In India’s current situation, rigorous scientific studies of China’s and Europe’s response to their early Covid-19 epidemics last year suggest that shelter-at-home measures may be highly effective in reducing transmission. Moreover, the timing of implementing these measures is critical. For example, in the case of Wuhan, China, just a few days of delay could have increased the total number of cases by one-third.

India should learn from the mistakes of its initial nationwide shelter-at-home order in March 2020, which critics have rightly noted was implemented in a manner that failed the most vulnerable groups in society. If a second nationwide shelter-at-home order is implemented in a similar manner, it could have devastating economic and social consequences.

Minimizing human suffering

To minimize additional human suffering caused by a new nationwide shelter-at-home recommendation, we believe that it should not be implemented unless it incorporates critical social and financial protections for India’s most vulnerable. Most importantly, the government should ensure access to food for populations who live below the poverty line, including migrant laborers, many of whom live on daily wages. These groups were the most adversely affected by last year’s nationwide shelter-at-home order.

India’s public distribution system, comprising ration shops that provide access to free or subsidised food, is widely available across the country. Enhanced provision of food rations is a core function of the public distribution system during public health crises, as outlined by India’s 2013 National Food Security Act. However, ration cards, which are needed to access the system, are usually issued locally and therefore often exclude migrant laborers, who then faced challenges accessing subsidised food during last year’s shelter-at-home order.

The public distribution system should ensure universal accessibility during periods of shelter-at-home recommendations by dropping requirements for a ration card. In addition, as most states only provide wheat and rice through ration shops, temporary expansion of what these shops provide to include other basic items, such as dal, should be considered.

Loss of livelihood is a separate challenge that could be mitigated by cash transfers to large sections of the Indian population to ensure they are able to pay for basic needs, such as water and electricity. Provision of such support may partly mitigate the adverse impact on migrant populations. In the absence of financial support, many migrant labourers were forced to return to their rural homes during last year’s shelter-at-home order, thereby contributing to increased transmission in rural areas – although some of this movement has already started during the current surge.

International aid so far has primarily focused on provision of oxygen and other medical supplies and vaccines; however, international provision of financial support to India could help the government to initiate large-scale cash transfer programmes similar to the support provided by the US and European governments to their populations. Reputed economists have outlined approaches for ensuring support provided through the public distribution system and cash transfers achieve the broadest reach among India’s most vulnerable populations.

Last year’s shelter-at-home order inadvertently resulted in major drops in care seeking for other serious medical conditions. The reported number of individuals being treated for tuberculosis dropped by nearly 50%, and HIV case identification in some facilities dropped by over 70% in some programmes. As doctors and public health specialists who work on research and clinical care provision for people with HIV and TB in India, we are very sensitive to these concerns.

However, in the current crisis, we must acknowledge that care seeking is likely even poorer. People are terrified of going to clinics and hospitals right now for fear of getting infected, and they are unlikely to receive any care at all in locations overwhelmed by Covid-19. In any wide-scale shelter-at-home recommendation, the consequences of individuals not seeking care for serious medical conditions need to be mitigated as part of public communication efforts. Use of telemedicine should be expanded to ensure timely diagnosis and continuity of care for other conditions.

Shelter-at-home recommendations are strategies that help buy time by slowing down the surge of patients overwhelming the health system and by providing an opportunity to scale-up vaccination. They are not a permanent solution. The shelter-at-home recommendation could be lifted on a planned basis, relying on rigorous surveillance data and vaccination coverage. Such an intervention has the potential to save lives during the greatest public health crisis faced in modern India; but it must build in robust social protections for India’s most vulnerable for this cure not to be worse than the disease.

It is easy to withdraw into fatalism given the severity of the crisis already. But we must remember that the situation is likely to get worse nationally – and there are still innumerable lives to be saved.

Dr Sunil Solomon is an Associate Professor of Medicine and Epidemiology at the Johns Hopkins University School of Medicine, Baltimore, USA and Chairman of YRGCARE, Chennai.

Dr Lakshmi Ganapathi is an Instructor of Pediatrics at Harvard Medical School and a pediatric infectious diseases physician and public health researcher in the Division of Infectious Diseases, Boston Children’s Hospital, USA.

Dr Ramnath Subbaraman is an infectious diseases physician, epidemiologist, and Assistant Professor in the Department of Public Health and Community Medicine in the Tufts University School of Medicine, Boston, USA.

Dr Shruti Mehta is a Professor and the Deputy Chair of the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.