Masks and handwashing vs physical distancing
Richard A Cash, Asif Saleh
Do we really have evidence-based answers for policymakers in resource-limited settings?
The public health community has communicated one message loud and clear to policy-makers: Complete physical distancing is your best hope of controlling Covid-19. Do it at any cost. And many governments have.
In India, where the government has asked 1.3 billion people to stay home for three weeks, literally millions have been left stranded, homeless, without work, and potentially going hungry.
Activists have accused the government of creating a socio-economic crisis through its public health interventions.
For the first time, more than half of the world’s population is under some form of movement restriction to reduce the transmission of an infectious disease. As more governments grapple with the immense difficulty of bringing their country to a halt, we see an important pattern emerging: Leaders from low- and middle-income countries are increasingly skeptical of mimicking policies that may have worked in China, South Korea, Germany, and elsewhere because of radical differences in demography, health system capacity, and cultural context.
Given the economic shock created by physical distancing policies, they are right to ask questions.
Our own assessment of disease modeling, such as that conducted by Walker et al, finds it is deeply, even explicitly, biased towards optimizing for the parameters of wealthy countries — on age distribution, the ability of families to self-isolate, assumptions on the capacity to scale up testing, and the ability to provide critical care and social support. We have yet to see models that optimize for younger populations in South Asia and sub-Saharan Africa, the extreme population density of megacities, high rates of inter-generational mingling, the likelihood of reverse migration, or the prevalence of other health conditions.
Critical care is unavailable in these societies and health systems will have no ability to provide lifesaving treatment to the vast majority of its citizens.
Public health experts seemed surprised to see physical distancing backfire — for example, urban migrants fleeing cities to avoid paying rent and be with their family during the crisis has occurred at an unthinkable scale.
Have epidemiological models accounted for the possibility that the policies could fuel widespread community transmission, rather than contain Covid-19? To those who know these populations intimately, it was the obvious consequence.
These models do not exclude just small pockets of people with unique circumstances. There are 1.2 billion people globally living in informal slums, which by definition are crowded and lack sufficient access to water and sanitation facilities, meaning any force of isolation or quarantine is impossible.
In some slums the density is as high as 800,000 people per square mile — for comparison, New York City’s is 27,000. If these policies turn out to lack efficacy, then the economic losses will have been for naught.
Is the global health community monitoring this risk and updating its advice?
In addition to over-prescribing physical distancing, the global health community should consider the emergency provision of food or cash as an essential, life-saving intervention to accompany forced loss of income.
These programs have lagged far behind, despite the fact that, for the 636 million people living in extreme poverty, severe food insecurity is immediate, predictable, and, in many cases, preventable through appropriate policies.
Lastly, and most crucially, we urge the global health community to better evaluate and promote infection control measures that are less disruptive to the livelihoods of the poor and feasible in low-resource settings.
Some of the best interventions we have, such as handwashing, are under-emphasized. The World Health Organization includes good respiratory hygiene as part of its standard guidance on how to reduce respiratory virus transmission.
Furthermore, many South Asian countries have factories where masks could be quickly produced at scale, getting some of the millions of workers in Bangladesh, Cambodia, Myanmar, and beyond back into factories that are currently closed due to the deepening troubles in the garment industry, while also enabling an infection control measure widely practiced in East Asia.
Already, India’s Ministry of Health has indicated that they are considering recommendations around home-made masks as a protective measure.
There are rapid examples of frugal, innovative improvisations popping up across the world, including some amazing crowdsourced entertainment on staying healthy, but the global health community remains too fixated on policies built for a different context to consider them seriously.
While it may be difficult for epidemiologists to consider policy options without meaningful physical distancing, the rapid expansion of widespread testing, and availability of critical care, this is the scenario most leaders in Africa and South Asia currently face.
They deserve every bit as much rigor and decision-making support as the leaders in wealthier countries. There is an opportunity to come out of this pandemic with more solidarity and equality, and in pursuing it we save more lives together.