by Sweta Dubey MBBS & Siddhesh Zadey BSMS
For the first time in human history, over 3.9 billion people in about ninety countries around the world were contained in lockdowns as of the first week of April. The current pandemic saw the rise of lockdown as a public health intervention since it was imposed in Wuhan, China, on January 23, 2020. While researchers and decision-makers have discussed the effectiveness of the lockdown for managing novel SARS-CoV-2, little has been written on the ethics of lockdown. For two decades, individual researchers, high-level bioethics commissions, and the World Health Organization (WHO) disease outbreak guidance have discussed the ethical implementation of quarantine. Some ideas have also been proposed, particularly for large-scale quarantine. Lockdowns in the current pandemic are large-scale quarantines with the added consideration that exposed and unexposed people are put under the same restrictions and might share the physical space. All these reports have consistently highlighted that evidence-based least-restrictive action, transparent communication, and reciprocal benefits to people for giving up their liberty are quintessential for any quarantine at any scale. The gravity of these issues only enhances in case of lockdowns (large-scale quarantines), where large quanta of the population are contained in a region with high stringency over freedom to move. In light of these, we put forward the ethical dilemmas and fallacies in the Wuhan lockdown as an example. Wuhan is a useful example to consider at the moment as it is an instance of the implementation of the first lockdown in the ongoing pandemic. The outbreak in Wuhan is now under control making the epidemiological background of our ethical inquiry less uncertain. Understanding the ethical lapses in the Wuhan example can be helpful in future epidemic control.
On December 26th 2019, a Chinese doctor detected a cluster of pneumonia of unknown cause in Wuhan city of Hubei province and raised the alarm for an impending outbreak. Transparent communication and timely dissemination of information during public health emergencies is recommended by WHO as it allows the public to take protective measures, enhances disease surveillance, avoids confusion, and improves the use of resources. Transparency was specifically important for China given that non-transparent response during the 2003 SARS outbreak was implicated in its global spread. However, there were attempts to stall the spread of information regarding the SARS-CoV-2 outbreak in Wuhan. Video platforms, news articles, and social media were censored, and doctors spreading awareness were labeled “rumormongers” and summoned by Wuhan police. Moreover, the Wuhan authorities downplayed the risk of the outbreak. Until January 15, 2020, the Wuhan Municipal Health Commission maintained that “there is no clear sign of human to human transmission.” On January 19th, authorities allowed a public gathering of 40,000 families in Wuhan to celebrate a traditional potluck festival. On January 20th, the Chinese National Health Commission insisted that the epidemic should be “manageable and preventable.” The mislabeling of information as ‘rumors’ by police and local authorities underplaying the outbreak made residents complacent. Against this background, the Chinese central government implemented a lockdown on a short notice of eight hours after its announcement at 2 a.m. on January23rd. This response generated panic and confusion among residents. Within two days how did a manageable outbreak transform into an acute emergency needing a city-wide lockdown containing 11 million people? What didn’t Wuhan authorities engage in transparent and timely communication with their residents?
From December 26th to January 20th, Wuhan authorities did not take steps like spreading awareness, promoting the use of face masks, social distancing, widespread screening, isolation of cases, and quarantine of contacts. Thus, the stringency of initial response was not proportional to harm i.e. the rising case counts. Without incrementally restrictive measures in place, Wuhan city was locked down on January 23rd. Lockdown is, arguably, the most stringent public health intervention that has negative effects of its own such as complete restriction of community movement and activity, disruption of economy and livelihoods, and closure of schools and other basic facilities. While now its benefit is known now, at the time of implementation, it was unknown how much effective lockdown would be against a novel virus whose infectivity, modes of transmission, and other epidemiological features were unclear. The lockdown was a high-cost intervention in an uncertain situation with an unpredictable outcome. According to WHO’s guidelines on managing the infectious disease outbreaks and previous influenza pandemic ethics case studies, the use of any public health measure restricting movement such as lockdown requires strong justification in terms of scientific evidence-based action and necessity. Local authorities could have initiated less restrictive measures with increasing stringency during the first three weeks of January. The proportional least-restrictive measures could have possibly avoided the need for lockdown altogether. Contrary to Wuhan, Zhengzhou, a city of similar population size (10 million) in the neighboring province of Henan implemented gradually increasing restrictive measures like disinfection, awareness drives, quarantine among the cases, suspension of trains from Wuhan, etc. starting from early January. On January 22nd, a day before the lockdown, Wuhan notified 1020 COVID-19 cases while Zhengzhou had two cases. Understanding the ethics of harm and necessity, why didn’t Wuhan authorities adopt timely, proportional, evidence-based steps to control the outbreak?
When the decision to lock Wuhan down was finalized, the interest of people outside Wuhan was clearly placed above those in Wuhan. The lockdown increased the risk of infection in uninfected people due to the close confinement with asymptomatic cases. People also suffered psychological distress due to isolation and anxiety due to uncertainty in the times of the epidemic. Those with pre-existing chronic health conditions like cancer, diabetes, and hypertension struggled to access healthcare. Wuhan is a major commerce and transportation hub in China. Thus, Wuhan lockdown affected economic activities in all of China and associated regions. Nearly 300 million rural migrant workers were stranded at homes in inland provinces or trapped in Hubei province. Did the authorities weigh the possible adverse consequences beyond of lockdown against its benefits for the outbreak control?
The Wuhan residents were eligible for reciprocal benefits as they suffered the loss of livelihood, bore restriction of basic movement, and possible depreciation of psychosocial health as a consequence of intervention against the coronavirus. It is noteworthy that the central and local governments promptly provided financial subsidies to patients, contacts, and medical personnel as a reciprocal action. Several banks adjusted and postponed loan payment without penalties. These benefits largely supported the middle class of Wuhan. However, many poor migrant laborers could not avail of the facilities granted by the resident registration system like access to healthcare, insurance benefits, etc. as their validity is limited to the city of birth. Moreover, migrant laborers were falsely portrayed as potential carriers of the virus, forced into quarantine by authorities, and expelled out of rented apartments by owners. The plight and discrimination faced by vulnerable sections ask for a more humanitarian approach by authorities and society. Couldn’t authorities have taken a more pro-active approach to protect the vulnerable migrant laborers in Wuhan who suffered disproportionately due to lockdown along with the outbreak?
Thinking about the questions raised above is critical for decision-makers if lockdowns make a comeback in the probable second-wave of COVID-19. Although we consider Wuhan as a case study here, similar transgressions against public health ethics have been committed in countries across the world. Public health ethicists should carefully assess the ethical transgressions in other instances such as the state-wide stay-at-home or shelter-in-place orders in the United States and the massive national-level lockdown in India that extended over a month. Upholding public health ethics is essential for the protection of the rights of people and can help in increasing the lockdown’s effectiveness and administrative feasibility with more significant people participation.