When proactive preventive measures against the covid-19 pandemic do not work, does it make sense to introduce coercive measures to reduce the chain of infections? Let’s look at the extreme circumstances that may justify a new population home confinement.
From the outset, we have emphasized that each and every person in our society has a responsibility to help contain the pandemic. For this we must firmly apply the 3M prevention measures (mask; hands-hygiene; meters-distance) and avoid 3C (poorly ventilated closed places; crowded; and close contacts).
On the other hand, the authorities had to minimize the transmission of the coronavirus by guaranteeing a good public health and primary care network, carrying out agile and reliable diagnostic tests (from which the cases would be isolated), and carrying out traces to identify and follow the patients. contacts (who must follow quarantine).
At this point, the cumulative incidence and mortality follow a worrying growing trend. While waiting for a safe and effective vaccine, it is necessary to establish additional measures that minimize social interaction and act in other areas of potential risk (such as reduced capacity or access restrictions in hotels or entertainment venues). Also coercive complementary resolutions such as the “restriction of mobility by zones”, the “perimeter closure” of municipalities or the “curfew” (in this case to carry out a severe control of night mobility).
In addition, there is another alternative, which is even stricter, and that we will examine: the home confinement of the entire population, either as we live it in spring or with some more lax aspects.
March 2020: the first confinement of our lives
Confinement was necessary in March when the new coronavirus tsunami assaulted our population and health care services were overwhelmed.
In this difficult context, a Royal Decree was urgently approved declaring a state of alarm for the management of the health crisis situation caused by covid-19. The goal was to flatten the curve through a collaborative social effort to avoid the collapse of the health system. That did not mean that in the long run there would be fewer infected, but that they did not all accumulate at the same time. In addition, it was a question of buying time in order to establish pandemic response systems to suppress transmission after de-escalation.
The spring confinement had the desired effect in that the curve flattened and the initial hit subsided. However, we know that it affected the physical and mental health of the population, at the same time that it hurt the economy. This had a great impact on the most vulnerable populations. Furthermore, the de-escalation was not very effective.
For all this, it was convinced to reserve confinement (a rudimentary measure, which was already used centuries ago in the event of epidemic episodes) for extremely justified situations. The foregoing was defended by the authorities of the Ministry of Health and the Autonomous Communities who, in a meeting on November 4, approved to unify the fight against covid-19 in a national strategy document designed within the Interterritorial Council of the National System of health.
The text made it clear that it ruled out imminent home confinement. Logically, there was no explicit reference to discarding it completely.
When may we have no choice but to return to home confinement?
The indicators established by Health to assess the situation include two fundamental blocks. One reflects the level of virus transmission (cumulative incidence, positivity, and traceability). The other, assesses the use of health services (hospital and ICU occupation). All according to numerical thresholds that we will not detail here.
We know that the thermometer that can justify confinement is the collapse of the capacity of the health system (reflected in the form of maximum occupancy of ICU and hospital beds by patients with covid-19, without the possibility of treating new patients, of this or other diseases ). It would only be justified for the time strictly necessary to regain the capacity for healthcare with basic guarantees.
Decisions to get to that point must be well-informed and communicated. It is about transmitting and understanding when to impose personal “confinement”, which also implies the closure of economic activity, and when to “reopen”. Essential to this is the use of data to decide when and where to locate landfills, and how decisions are made and applied.
If it’s justified and done properly, lockdown works. There are studies that indicate that this measure can reduce mortality between 31 and 76% and the incidence of new cases between 44 and 96%, according to a recent Cochrane Review. The measures appear to be more effective and less costly the earlier they are started.
Before continuing, a note: Cochrane Reviews come from a prestigious non-profit organization that brings together more than 30,000 volunteer researchers in more than 90 countries, who follow a rigorous and systematic review process of health interventions.
In this same review on quarantines and lockdowns, Cochrane researchers acknowledge limitations in their study data that make those conclusions not entirely certain. They emphasize that the designs in the original works are observational and did not include a comparison group without quarantine. In addition, they based their models on partial data that assume different starting criteria about the virus (for example, how fast it would spread).
In any case, Europe has already started the lockdowns again. Despite the great suffering and economic degradation they generate, their governments have deemed them necessary in certain circumstances.
If the time comes, what principles should one keep in mind?
As confinement affects fundamental rights, for its effective implementation the broadest possible consensus would be necessary. It is essential to legitimize its articulation through a state of alarm in accordance with the Spanish legal system.
In the event that it is decided to take the step towards population confinement (total or by autonomous communities, according to indicators), in my opinion the authorities should bear in mind the following points:
- Leadership and political legitimacy to make and implement a decision of such depth with reasonably widespread social acceptance.
- Ensure that you have reliable data and analysis that becomes intelligible information, evidence and intelligence for action.
- Guarantee the necessary financing, because these measures imply an economic cost.
- Show effective willingness to consult and involve the main sectors affected.
- Anticipate policies that address specific sectoral risks. For example, those raised by the school system, colleges, and high-density workplaces.
- Introduce or modify stabilizing social policy measures in order to minimize the impact of the pandemic on people, groups and businesses particularly affected.
- Design and support policies to guarantee support to the National Health System, both in public health aspects (test, traceability, isolations and quarantines) and assistance (treatment and rehabilitation of patients).
- In addition, it is essential to articulate communication strategies that inspire credibility and trust. It must be reported and communicated avoiding both false triumphalism and hesitation and contradictions. Explain why, where, how, when and for how long it is necessary to introduce measures. The so-called “pandemic fatigue” is becoming more and more real and can only be tackled with credibility, scientific basis and good information.
José María Martín Moreno, Professor of Preventive Medicine and Public Health, University of Valencia
This article was originally published on The Conversation. Read the original.
