As the smoke from countless funeral pyres rises above our cities, and desperately sick people line the corridors and wards of our hospitals seeking beds, medication and oxygen to relieve their virus-damaged lungs, it is difficult to see a way out of the worst crisis India has faced since the plagues and famines of the 18th and 19th centuries.
The anaemic pace of the government’s vaccination drive is unlikely to slow the ferocity of this second wave of the pandemic, which epidemiological modellers predict could peak by the middle of May and gradually decline. If there is one thing to be learned from the tragedy unfolding before us, it is that unless active measures are taken, this second wave will be followed by a third wave, and perhaps more.
Waves across the globe
If we look around the world, the United States has had three distinct waves since last March, as has Brazil. The United Kingdom had a small first wave, followed by nearly four months when cases were low and the virus seemed to be disappearing. This was followed by two explosive waves, which only subsided after a lockdown and an aggressive vaccination campaign in which 95% of all those over the age of 50 have been vaccinated to date, with the entire adult population to be vaccinated by the end of summer. South Africa saw a first wave peaking last August , followed by a second wave that began around November, and peaked in the first week of January.
Given this pattern, a second wave in India was almost a given. And once this wave recedes, it is highly likely that a third wave will build up, unless active measures are taken to stop it building up. Now is the time to think ahead and find ways to prevent the next wave.
Vaccines are the best option. But given India’s population, the slow pace of vaccination, inelastic vaccine supplies both in India and globally, and limited finances with State governments which have now been given the responsibility of vaccinating the bulk of the country’s population, this is not going to happen quickly enough to blunt either this or future waves.
Tested methods that work
So along with vaccination, it is important to practise the full methods that have been shown to slow the spread of COVID-19 in different parts of the world: mask wearing, physical distancing, hand hygiene and a ban on mass gatherings.
These measures sound mundane and boring, but they work. They may not be as effective as mass vaccination, but in the absence of vaccines, they are perhaps the only way to reduce community transmission and slow the spread of the virus. Consider some of the evidence demonstrating the effect of these measures.
A study last year in the American Journal of Tropical Medicine and Hygiene found that countries where masks were widely used (either because of government orders or cultural norms) had lower per capita mortality from COVID than countries where there was no universal masking. A smaller study of transmission among family members in Beijing households, found that face masks were 79% effective in preventing transmission when they were used by all household members.
A comprehensive review of the scientific evidence for the use of face masks , published in January this year in the Proceedings of the National Academy of Sciences (PNAS), concluded that “near-universal adoption of nonmedical masks when out in public, in combination with complementary public health measures” could reduce community spread, provided the measures were sustained. Mask wearing by itself will not be enough: it needs to be part of a package of measures that include rigorous social distancing, hand hygiene and avoiding mass gatherings.
The question is how can people be persuaded to wear masks? Conventional wisdom in India has it that wearing a mask only works when it is imposed as a police measure, with fines and punishments for non-compliance. Mask wearing and social distancing cannot be sustained through lathis . Public health measures that work best are those that the public voluntarily adopts because they see it as being in their best interests.
Bangladesh shows the way
But there is evidence from an experimental study in Bangladesh that people will use masks enthusiastically if they are provided free, are comfortable, and accompanied with appropriate instructional material. A team of researchers, led by Mushfiq Mobarak of Yale University, carried out an experiment involving 350,000 adults in 600 villages in Bangladesh to try and understand how to increase mask usage. They found that mask usage tripled when they were given away free and accompanied by well-designed instructional material, as well as reminders from religious and community leaders and volunteers. These interventions increased the percentage of people using masks three fold.
Having volunteers in public spaces such as markets to remind people to wear masks and distribute masks to those who did not have them, as well as frequent messages from religious and community leaders, saw an increase in mask usage from 13%, when none of these interventions existed, to over 40% with them. One key to success was mask quality: masks needed to be comfortable to wear in hot and humid conditions, as well as being effective filters. Importantly, those who wore masks were also more likely to maintain social distancing.
Over the last year, India has built significant capacity to manufacture masks, so supplies should not be an issue. The cost of supplying reusable masks free will need to be budgeted for, but masks are far cheaper than vaccines and the economic benefits of avoiding crippling new waves of the virus should be taken into account.
Reaching out the right way
Communication at the level of communities is the key to getting people to protect themselves this way. People need to be explained the reasons for mask wearing as well as the right way to wear a mask. Imaginative and creative communication campaigns are essential. In Bangladesh, community-level leaders as well as religious leaders were used to reinforce mask wearing and social distancing messages. Most Indian States have reasonable, well-functioning networks of health workers at the village and community levels who can be used in health campaigns.
These solutions may seem simplistic, but if the country is to reduce the impact of future waves, it is essential that they are put in place. Viruses are the most basic of organisms. And often, basic changes in human behaviour can drastically reduce the ability of a virus to transmit. Vaccines are the ultimate solution. But in the meanwhile, it is important to focus on what can be done right now if further disasters are to be prevented.
Thomas Abraham is adjunct associate professor at the University of Hong Kong and author of Twenty-First Century Plague: The Story of SARS and Po lio: The Odyssey of Eradication. He has been a communication adviser to the World Health Organization
