As the Covid 19 curve shows signs of flattening in some parts of India, leaders at the Centre and across the states are grappling with how and when to start loosening the rules of lockdown, while avoiding a dangerous resurgence of the virus. Conditional lifting of lockdown from April 20 was announced by Prime Minister Narendra Modi. While many of the states have approved the partial lockdown measures, some of the states have decided not to revoke the restrictions amid the surge of COVID-19 cases in their home state. States favouring partial lockdown are either COVID-19 free or have been relatively resilient in containing the spread.
Manipur was declared COVID-19 free on April 20 by chief minister N Biren Singh after two patients undergoing treatment tested negative. The CM rightly credited the achievement to public cooperation, dedication of medical staff and strict enforcement of lockdown. Largely, the lockdown and curfew were responsible in breaking down the chain of transmission thus preventing the escalation of infection. How did it do? What can we learn from the experience of 40 days’ lockdown?
Political and administrative leadership
In the face of COVID-19 crisis, the agenda of protecting people’s health and the fight against the virus received committed assurance and support from all political parties in Manipur. While the department of health – directorate of health services, Regional Institute of Medical Sciences and JN Institute of Medical Sciences provided the technical leadership, the state witnessed optimistic response, cooperation and close coordination with the central leadership and across different government departments in the state and districts.
Political leaders at the ministerial level along with district authorities were involved in monitoring of COVID-19 related activities and ensured peoples welfare across the state. The political and administrative leadership effectively used small group meetings with civil societies, communicated with the larger public through print, electronic and social media in explaining the purpose of sudden lockdown; preventive measures and to avoid stigma. On confirmation of first positive case on March 24, another 24×7 COVID-19 common control room with helpline was set up at Darshan Hall, CM Secretariat with the objectively to rigorously monitor COVID-19 related activities. In addition, Rapid Response Teams (RRTs) were made functional in all districts in order to respond to the emergencies related to the pandemic.
Considering that the ordinary provisions of the law was insufficient and to empower authorised officials, the State Government issued the Manipur Epidemic Diseases, Covid-19 Regulations, 2020 on March 23, 2020. Violation of any provisions is punishable under section 188 of the IPC (45 of 1860) and it provides adequate power to the state officials to take necessary action for the purpose of preventing the outbreak of the disease. For examples, on March 22 an order was issued to all individuals who were outside the country within the period from January 1, 2020 to February 29, 2020 and have entered Manipur after March 1, 2020 were ordered to contact home department, government of Manipur. Over 700 people responded to this order. On April 1, on confirmation of the second COVID-19 positive case in Manipur; as per the regulation restriction order on movement were imposed and district police maintained a strict vigil in the sealed area, including use of drone.
In order to monitor the COVID situation and to take forward on the lock-down exit strategy a state consultative committee for COVID-19 was formed on 23 April. It has 21 members with representation of cabinet ministers, MLAs from across political parties, high level civil and health officials and representation from private hospital and laboratory of the state. On April 26, a memo from the Chief Minister’s office was issued to all the MLAs for arrangement of Community Quarantine Centre in their respective constituencies; for people (about 12,000) who are currently stranded outside the state.
Crisis arising out of pandemic has the potential to cause systemic paralysis and thus pose a major risk where the political and administrative leaders disassociate, engage in policy paralysis or fails to identify the threat until it leads to irreversible and undesirable damage. Unfortunately this is exactly how some major countries seem to have responded, thus experiencing undesirable catastrophe.
On the contrary, the Manipur state government and its administrative leadership were responsive, prompt in making bold political and administrative decisions. Imposition of curfew, in addition to total lockdown and invoking the constitutional provision of the Manipur Epidemic Diseases, COVID-19 Regulations, 2020 were well-timed and forceful. Very soon, leaders will have to start making decisions about lifting lockdown policies. The exit strategy, should aim at achieving a fine balance of normalizing economic and social activity and yet keeping the virus under control. Since the virus and its course so unpredictable the exit strategy should be evolutionary, constantly supplemented and is based on the latest statistics and the impact of the previously implemented measures.
Prompt preventive and containment measures
The leadership in Manipur, realising early that the virus could be brought to the state through infected people, were quick to implement various preventive measures much before WHO declared COVID-19 as pandemic. For example to name a few, screening of passengers arriving at Imphal airport started from the 18-01-2020, well before any state. International border gates with Myanmar were also closed on 09-03-2020, making Manipur the first state to seal the International border.
Manipur became a potential ‘COVID-19 hotspot’ when the first positive case was detected on the March 25, a 23-year-old woman with travel history to UK; the second case, on April 1, a 65-year-old man, a returnee from the Tablighi Jamaat event in Delhi’s Nizamuddin. The government was quick to respond with a drastic decision by imposing curfew on March 24, in addition to the lockdown activated on March 22. Besides ensuring treatment of the patients at RIMS and JNIMS, the state and district authorities also left no stone unturned in their containment efforts by tracing contacts, instituting quarantines and locking the hot-spot locality.
For example, the first positive case was detected on March 24. Within a span of 2 days (26th March) district-level authorities were able to trace the contacts and effectively quarantine all the 195 co-passengers. The second positive case was confirmed by evening of 1st April. The geographical area of Lilong (hot-spot) was completely sealed off; restrictions were imposed on public movement on the same day. Within a span of three days (April 4) all the 49 close contact people tested negative and were quarantined.
Perhaps, the best and only alternative preventive measures available during the early phase of COVID-19 were of sealing international and inter-state borders; screening of inbound travellers, imposition of lockdown and curfews by invoking the Manipur Epidemic Diseases, Covid-19 Regulations, 2020. The intent of these measures was to prevent importing virus into the state; early on, identify and segregate infected people. Lockdown and curfews, use of masks and social distancing aims at the same – to stop community spread of COVID-19. The lesson was clear; acting early against a health threat is less risky and more effective than vacillation.
Dedicated border screening sites, surveillance team and testing centres
Manipur’s COVID-19 surveillance system is embedded in the existing Integrated Disease Surveillance Program (IDSP). Since January 18, there are 7 dedicated screening sites at border entry points to Manipur; 1 at the International airport and 3 sites dedicated to truckers. A major focus of this response is on case detection. In a prescribed format, these screening sites submit daily reports to the IDSP team at the district and state level. As of this writing 193,643 were screened for symptomatic infection. On 1 April, ICMR approved two COVID-19 testing centres at JNIMS and RIMS. So far, 368 samples are tested. Availability of testing facilities at the state has been beneficial in providing quick results for immediate decision and action. Unlike in the past, specimens were outsourced outside the state for testing. It was time-consuming and additional logistic burden.
Critics have been skeptic on just two positive cases and low testing in Manipur. While testing is important in identifying cases; until now only those people presenting with symptomatic case are tested. As testing in the community level would require additional resources like trained personnel, equipment, PPE; it may also create unnecessary panic in the community, therefore the rationale in limited testing. However, as leaders plan to lift the curtain of lockdown and repatriate stranded Manipuris from other states, the approach to testing may need further deliberation.
Moving beyond the lockdown
As Manipur looks forward and is steadily moving towards beyond the lockdown phase, the word in this period would be ‘vigilance’. We believe that lockdown has been an opportunity for Manipur to strengthen its surveillance system, pressing into service of a large number of health care workers for screening, contact tracing and isolation and improve its testing capacity. The leadership now needs to be vigilant in protecting the health workforce, by ensuring adequate personal protective equipment as the health system is only as strong as its health workforce. Beyond COVID19, the state should revive its vigilance and focus on providing services and care to the other equally important health conditions, therefore the need for an ongoing strengthening of health systems at the community and peripheral health facility level.
In addition, vigilance will be needed by the communities to adjust and adapt to any ongoing distancing measures put in place by the government. Permitting market and shops to open but maintaining the physical distance of 1 meter will allow the economy to function while having some benefits in preventing the spread of the virus. Mandatory use of mask in public spaces will also send a clear message that there is an ongoing crisis. By far the most critical factor in this period will be the citizen themselves. Behaviour change happens at home and in the community, this is where vigilance will be achieved. The leadership must broaden its level of engagement with the community at various levels – the civil societies, local NGOs, transport unions, youth organizations, village councils, celebrities and student unions – to achieve acceptance of emerging social norms and realities.
Every crisis is a threat, but it also presents opportunities for continued learning and innovation. Emerging victorious from the crisis is extremely dependent on how well each government is able to face it head-on and, bring society on board while coordinating effectively with stakeholders. This is a test for our governance system; hope our collective response will take us safely to the ‘New Normal’.
(Dr Priscilla C Ngaihte is advisor to Public Health Foundation of India; Lipekho Saprii is director, Springfield Academy, Manipur. Both authors are public health specialists. Views expressed are personal)