Dr. Somchai Jitsuchon*
I believe that the question many people have in mind at the moment is that what will happen after the end of the lockdown on April 30? Will it be extended?
Will it be extended with less strict measures considering the recent decrease in the number of infected people, or will it be extended with stricter measures because the number of asymptomatic people is still unknown. Most people may have realized that it is impossible to completely lift the lockdown and return to normal. The options that remain are whether to continue the lockdown as it is, relax the measures, or implement stricter measures. This decision is extremely important because there will be impacts on the ability to contain the outbreak in the next phase, the overall economy, and on how the poor and the underprivileged manage to overcome this crisis.
Firstly, it is important to understand that shutting down cities is a compulsory measure in order to facilitate the practice of social distancing. In fact, there are other measures that help reduce the outbreak, such as compulsory mask wearing when outside or in crowded areas. Some countries prohibit ‘a gathering of 2 or more’ except for members of the same family, etc. And there are also at least 3 groups of measures that do not need compulsion, which consist of
(A) Educating people on how to prevent infection. Tell them what they should do, what is effective, but do not force them to do so do. Example measures as wearing a mask every time when going outside, washing hands regularly and correctly, and keeping distance of 2 meters from other people. These measures have already been implemented and seem to be effective because people are very enthusiastic.
(B) Encouraging establishments or places to voluntarily implement their own measures voluntarily, such as taking the temperatures of visitors, not allowing entrance to visitors who do not wear masks.
(C) Increasing testing capacity among asymptomatic patients or people with suspected symptoms. The government can also track risk groups, and put them in quarantine in places provided by the state or at home.
Lessons from abroad
That the lockdown measure has been widely used is believed to come from a lesson learned in China which closed the city of Wuhan and was able to contain the disease. However, the ‘success’ of controlling the spread in South Korea which did not implement lockdown has raised the demand for the measures in group C. South Korea has shown that even without the implementation of lockdown like in Wuhan or Italy, it could maintain the increase rate of patients to lower than 1 percent after the number of accumulated patients rose to 10 thousand in early April, and decreased steadily after that. Compared to European countries and the United States, South Korea is considered very successful in controlling the pandemic. In Italy, the rate of new patients was increasing by as high as 15-20% at the moment when the number of accumulated patients was about 10,000. It started to show signs of slowing down, but the increase rate was still 3-4% when the number of accumulated patients reached a hundred of thousands. Many people, therefore, see the success of South Korea as the ‘light at the end of the tunnel’ that Thailand should imitate.
Taiwan is another compelling case to support the use of group C measures. The number of accumulated patients on April 7 in Taiwan was only 376 people, representing a patient-citizens ratio of 16:1 million, or 50% of that of Thailand (32:1 million) despite Taiwan being among the first countries to have confirmed cases (1 week after Thailand) and taking 56 days just like Thailand to see the number of patients accumulating to 100. However, the rate of increase has been much slower than Thailand. Like South Korea, Taiwan does not implement lockdown although more than half of the patients are in Taipei and New Taipei. Compared to South Korea, Taiwan conducted fewer tests, or approximately 1,500 people per million. That’s only about one-sixth of South Korea. Taiwan’s strength, therefore, seems to come from the ability to track risk groups and implement quarantine.
What to be aware is that it is not easy to interpret those numbers as success or failure. We cannot say that by implementing group C measures, it is alright to relax the lockdown measures or other measures. In reality, there are still many other factors involved, such as citizens’ knowledge of disease prevention, the level of voluntary cooperation, and measures of establishments and organizations. All of these factors could be game changers. For example, many people believe that having everyone wear a mask is a more important factor (as they believe that masks are not just for patients as stated in WHO’s guideline which many countries in Europe and America followed at first, and not until the outbreak was in a critical state that WHO recommended everyone to wear a mask). Japan is another country without lockdown but sees a small increase in patients: it took 66 days for the number of accumulated patients to reach a thousand, which is much longer than other countries. It does not conduct a lot of tests either (only 300 in one million, or one-fifth of Taiwan, and one-thirtieth of South Korea). This may be partly because of cultural factors, such as a custom on social distancing and national cleanliness. The severity of the pandemic in Italy could be attributed to cultural factors as well.
Therefore, I propose that we combine many measures in an appropriate proportion and in accordance with the socioeconomic context of Thailand. My suggestion on how to lift the lockdown after April 30 is as follows:
What we absolutely need to do
The first thing to do is to educate people about self-protection in a variety of settings whether when living at home with family, in a dormitory, in a condominium, or when going out to buy fresh food, in a minimart, in a shop, etc. They should know what kind of travel is safe, such as travelling by a boat that is ventilated is less risky than by an air-conditioned bus. This knowledge must be disseminated to all areas, all demographic groups, all classes, statuses, and more importantly, it must be done in a way that effectively encourage people to apply these knowledge voluntarily.
At the same time, the existing measures, such as testing, tracking, and quarantine, must be more comprehensive and stricter and implemented in every outbreak to prevent the infected and at-risk groups from having the opportunity to spread the virus. Regarding the testing capacity, it is reported that the capacity is increasing rapidly and will soon be able to conduct more tests, even not as many as in South Korea and Germany. Yet, tracking and quarantine is the area that needs improvement, for example, by using telemedicine to sort out who should be tested, who should be quarantined. This is how we serve a large number of people using a small number of medical personnel, and reach out to communities in remote areas.
Gradually lift the lockdown
Once all of the above measures have been put in place, we will consider gradually lifting the lockdown. We must first classify the places that are currently ordered to be closed or restricted operations (Currently there are 34 types in Bangkok area.) and then consider (1) the risk of outbreak due to natural factors (2) the possibility to mitigate the said risk with a reasonable budget, which needs to be discussed in detail for each type of business/activity (3) how much of the economy will be recovered if risk-mitigation measures are implemented. The use of these 3 criteria must be backed by academic reasons (including epidemiological evidence and economic analysis for benefits and costs), such as the possibility to do social distancing, air flow, behaviors of people involved in the activities in those places, etc.
My preliminary proposal is to continue closing establishments that tend to be crowded, are difficult to practice social distancing and not well ventilated, where users tend to be careless or not comply with prevention measures. The establishments in this group include, such as, boxing stadiums, entertainment venues, pubs, bars, concert performances, cinemas, snooker venues. It is an opportunity to effectively shut down illegal gambling places not only because they are illegal but also because they are sources of infection transmission.
For the remaining establishments, I would like to separate them into a public service group (schools, museums, libraries, large-scale businesses) and a small-scale business group run by middle-class and grassroots entrepreneurs. For the first group, the government should declare measures in detail to reduce the risk, such as no entry to people with fever, compulsory mask wearing for everyone, sitting apart, keeping hands clean, etc.
For large-scale businesses, the Chamber of Commerce and the Federation of Thai Industries should prepare concrete and detailed pandemic prevention methods and inform these establishments when they are allowed to resume activities. For example, the Thai Retailers Association should inform a mall to take a temperature of every customer before entering the premises. If found to have a high fever, the customer will not be allowed inside. Monitor customers to make sure they stay no less that 1.5 meters apart (except those coming together), wear masks, and use alcohol rub provided every 20 meters. etc. The Thai Retailers Association should also submit these detailed measures to the government to be assessed by an impartial epidemiologist. Once a conclusion is reached, certain establishments will be allowed to reopen, and outbreak data will be collected as a result of customers coming to shopping malls.
Brainstorming
The small-scale business group presents a challenge for formulating mitigation measures due to its wide variety, such as barber shops, beauty salons, and small restaurants. The owners may not have the knowledge or funds to hire epidemiologists to help design measures. I suggest forming a central committee, be it a government agency, a foundation, a university or a research institute, to be in charge of crowdsourcing ideas about what kind of measures each type of business should come up with to mitigate risks in a practical and empirical way. For example, in China, where the situation begins to be under control and the lockdown lifting process is starting, people are allowed eat in restaurants. Small bistros that do not have enough space for proper social distancing have to make partitions between tables, etc. These seemingly trivial yet effective ideas cannot come from the government alone. It takes diversity and imagination of the crowd. Examples of crowdsourcing are, the exchanges of people on Pantip website, or creating a brainstorming platform where the committee in charge can compile and classify ideas for each type of business, and then have epidemiologists, economists, and business executives consider which proposals will be the most effective and cost-effective.
Trial, evaluation, adjustment to mitigate risks
Once the risk mitigation measures are established for all types of businesses, the government has to announce them. The measures should be divided into compulsory ones and recommended ones. There are penalties for those who do not follow the compulsory measures. Then, start a two-week trial after April 30. During the first phase, the measures may be applied in certain parts of the country, such as inner Bangkok or some provinces as experimental areas. The trial could be done in multiple areas with different sets of measures to evaluate which combination is more effective. After two weeks, the government may order another lockdown as before April 30, since the virus takes around 5-7 days to incubate, to study the outbreak data collected from each area until a conclusion is reached as to whether or not we should move forward, or how we should adjust the measures. In the meantime, measures should be taken to reduce inter-city travel in order to reach an accurate conclusions and help reduce the spread of infection to other areas.
This proposal is only a broad idea. I would appreciate if all of us help improve it so that we can have a good guideline on how to gradually lift the lockdown, prevent the disease from spreading further while ensuring that the economic sector can resume its normal status, and most importantly, the suffering of the poor is alleviated. If so, government measures to remedy the economy will also be less costly.
*I would like to thank Dr. Tanarak Plipat, Deputy Director-General, Department of Disease Control, who inspired a great many ideas in this article
This proposal is part of “TDRI Policy Series on Fighting COVID-19”