COVID-19 Pandemic Control - Why simple is not easy

In order to arrest the spread of COVID-19, which is wreaking havoc world over, we need to follow simple things like washing our hands and exercise social distancing. But these seemingly simple things are tough to follow as they are not part of our habits, changing which might not be as easy as it sounds, writes Dr. Dileep Mavalankar, Director of the Indian Institute of Public Health, Gandhinagar.

Hyderabad: In the COVID-19 pandemic, what is to be done to halt its spread is simple. It is by now repeated millions of times. Cover your nose and mouth with handkerchief or tissue, do not spit, wash hands frequently for 20 seconds, do not touch your eyes or note or mouth, do not shake hands – do Namaste, social distancing – keep 1 meter away from others. All these are simple steps almost known from 1918 flu pandemic times – nothing new – nothing complicated, nothing expensive... But "simple" things in life are not "Easy to do" - why?

In spite of a major pandemic ongoing, media, mobile ring tones and leaders telling about it almost for a month and cases and death numbers increasing day by day, when we see the behaviour of people, it has not changed much. People still cough in open without covering their face, spit on the road, scratch their face and nose, stand in a crowd, shake hands and hug... People coming back from infected countries attend parties and enjoy themselves... Why is this? And what needs to be done to change this?

There are several reasons why changing simple-looking patterns of behaviour are not easy. First, these are long entrenched behaviours and part of the local culture – shaking hands, hugging. It is a learned behavior which gives pleasure and feeling of warmth or friendliness. Coughing, sneezing, and spitting are also part of biological and learned behaviours. It is part of habits – and changing any habits and learned behaviour is not easy at all. Many of the related actions are reflex behaviours done without much thinking.

Secondly, in health psychology there is a concept where everyone believes that the disease or bad things generally happen to the "public" or to the "other" persons, "not to me or my family. Hence I can listen to the advice, even give the advice to others and believe that it is really true and useful but subconsciously feel that I need not practice it." And hence we do not bother to decide to change the habits for ourselves.

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Thirdly, many simple things are not easily available. Take the example of advice to wash hands repeatedly for 20 seconds with water and soap. Many places in India – streets, offices including government offices, railway and bus stations, schools and colleges, even restaurant toilets and hand washing facilities are non-existent, not working, not having water or soap and in a terrible condition. Many homes have very little water, and no running water and very little soap. And finally, 20 seconds is a long time if you time it by the watch. My rough estimate is that not even 1 per cent of the population may be doing it – if we exclude the surgeons and people with OCD. Generally, handwashing is done in 5-7 seconds. So, easy to say, "wash hands for 20 seconds" but difficult to do.

Now touching the eyes, nose and mouth or face is part of our habits, style and at times, biological need. After starting of the epidemic over the last month, I am observing my own behaviour in this regard and that of many other very well educated professionals with whom I have had the chance to attend many meetings with. In all of them, I have seen people repeatedly touching their eyes, nose or face. This again is as a matter of habit or reflex action to some minor irritation in the nose, eye or to wade off boredom or sleep, and what not. These habits are also difficult to change. Some of it could be developed over generations and embedded in evolutionary biology to keep our eyes, nose and mouth protected and functioning.

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Next - the habit of crowding, falling over one-another is perhaps coming out of our population density, our uncertainty of being served in a queue in an underserved and disorganised country or our biological need to be close to other humans whom we love. Indians want to celebrate and showoff by inviting large gatherings – be it social, commercial or political – our belief is that numbers are our strength. We as a nation do not seem to believe in appointment system – hardly any public office and many private officers work by appointments. We need to queue up and crowd to get any service. And our queue discipline and sense of queue justice is very poor to say the least. Again, changing this is also not easy. Major policy reform and mindset change is needed. We need to decentralize, democratize and increase the supply of services so that crowds do not need to gather.

Breaking habits needs education, information and communication – but that is not enough. It also needs repeated practice – a drill. Recently, there is good example – in many cities in public gardens people gather and run "laughing" clubs – they come together and practice – artificial laughing – similar to a drill master ordering the drill – a laughing club coordinator makes everyone practice the art of laughing as a drill. To change habits, we need to do exactly the same – ask people to practice – like a drill – coughing in the elbow or in a handkerchief, rubbing nose or eyes with handkerchief. We have to do a practice drill of standing at one meter and talking or greeting without shaking hands or hugs.

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As part of the "Smart City" projects, we have to ensure that there are adequate toilets and handwashing facilities in public and private buildings with adequate water and soap. Building codes have to change to make them handwashing guidance compliant. The standard size calculations of the water tanks will have to be increased as 20 seconds hand wash frequently with soap will need much more water than two minutes without soap.

Finally, our sociopolitical power perceptions may have to change from the numbers in the crowd to some other method of gratification and sense of accomplishment – in this, may be social media may help. May be this is the toughest challenge. Here again, like the laudable 'Janata Curfew' idea of the Prime Minister, we can evolve a moral code on gatherings to max of 300- 400 for parties and may be a 1000 to other mass gatherings.

So the simple things needed for COVID-19 pandemic control are not at all easy. But they are all doable if we as a nation and society decide to do. To fight this pandemic we have to do this very fast.

(The author is Director, IIPHG. The views are personal)