Abstract
Social distancing refers to a host of public health measures aimed at reducing social interaction between people based on touch or physical proximity. It is a non-pharmaceutical intervention to slow the spread of infectious diseases in the communities. It becomes particularly important as a community mitigation strategy before vaccines or drugs become widely available. This essay describes how a protracted adherence to social distancing guidelines could affect the Indian society. Changes are expected in some of the prevalent cultural norms such as personal space and common good. Gender relations within the family are likely to change in favour of greater sharing of domestic responsibilities between men and women. Older adults may particularly experience stress due to social distancing because of their physical dependency and emotional vulnerability. Working patterns are likely to become more flexible and promotive of social distancing. Human interaction based on digital technology is likely to increase. The implications for public health in India due to such changes are also discussed.
Background
Social distancing refers to a host of public health measures aimed at reducing social interaction between people based on touch or physical proximity. This can include ‘remaining out of congregate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible’ (Centers for Disease Control and Prevention [CDC], 2020a). It is a non-pharmaceutical intervention to slow down the spread of infectious diseases in the communities. It becomes particularly important as a community mitigation strategy before vaccines or drugs become widely available (CDC, 2020b). It is estimated that without social distancing measures in place, a COVID-19 positive person can infect 406 persons in 30 days. If social distancing measures are in place and social exposure is reduced by 75 per cent, then an infected person can spread the infection to only 2.5 more persons at the end of 30 days (Lu, 2020).
As COVID-19 spread in India, social distancing guidelines were issued by the union and state governments. The union government has proposed, inter alia, closure of all educational establishments (e.g., schools and universities), gyms, museums, cultural and social centres, swimming pools and theatres; postponement of examinations; encouraging employees in the private sector to work from home; conducting meetings via video conferencing facility, where possible; maintaining distance of 1 metre between tables in restaurants, between persons in mass gatherings, customers in shops, etc.; restricting planned weddings to a limited gathering; and the like (Government of India, undated a). The state government in Delhi banned ‘religious, social, cultural and political gatherings as well as protests comprising more than 50 people’ till 31 March 2020 (Times of India, 2020). Various other states issued advisories on social distancing. Soon after, countrywide lockdowns were enforced to limit the spread of the disease. As on date, India is under its third lockdown. The first was a ‘Janata Curfew’ observed on 22 March 2020. The second lockdown was for a 3-week period with effect from 25 March 2020. It was further extended till 3 May 2020. Limited activities were permitted during the lockdowns. Public transportation remained closed during this period, as also educational institutions. Only specific industrial and commercial activities and hospitality services were allowed to function. Cinema halls, malls, shopping complexes and other public places were shut down. Gatherings were disallowed. These included all ‘social/political/sports/entertainment/academic/cultural/religious functions/other gatherings’. Places of worship were closed for the public. Funerals could be attended by a maximum of 20 people (Government of India, 2020). The rules are being eased gradually. At the time of writing this article, standalone shops have been allowed to be open subject to the final decision of the respective state governments and union territories. They shall function at 50 per cent of their workforce. Social distancing has to be practised and masks have to be worn. Shops shall, however, remain closed in COVID-19 hotspots and containment zones (Economic Times, 2020, April 25). In the state of Uttar Pradesh, there has been a ban on public gatherings till 30 June 2020 (Business Standard, 2020).
Thus, the lockdowns run concurrently to the social distancing guidelines. Guidelines on social distancing are advisory in nature. Lockdowns, in contrast, are enforced by the state. Lockdowns are akin to fighting a fire. They help contain the spread of COVID-19 and limit it to areas by halting activities. They also boost compliance with social distancing guidelines, especially in public places. However, continuing with lockdowns for a long time would be ruinous to a country and its economy. COVID-19 is expected to last for years (Kissler et al., 2020). Social distancing measures, which are voluntary in nature, can continue and shall help in limiting the spread of the disease. It has been projected that prolonged or intermittent social distancing may be necessary till 2022 to limit the damage due to COVID-19 (Kissler et al., 2020).
Review of Literature
Social distance is a social science concept. It refers to the feelings or relations of ‘aloofness and unapproachability’, especially between members of different social strata (Jary & Jary, 1991). It is practised in all societies in varying degrees. The concept was popularised by Emory S Bogardus in the USA about a century ago. He observed that ‘social distances exist between different groups of people as well as between persons’ and its ‘chief significance’ is to maintain status (Bogardus, 1926). However, social distancing as a public health measure during pandemics has been inspired by practices during the Middle Ages. Lipton and Steinhauer write that social distancing became part of the federal policy of the USA about a decade ago. It was used limitedly during H1N1 influenza outbreak in that country in 2009. It is during the current COVID-19 pandemic that social distancing has been implemented across the USA for the first time (Lipton & Steinhauer, 2020).
Though social distancing became a part of federal policy of the USA in recent years, it has been practised for several decades now. It has been a recent focus of investigation too (Aledort et al., 2007). During the 1918 influenza pandemic in that country, cities witnessing early introduction of social distancing (and other interventions) had lower peak death rates and less steep epidemic curves (Hatchett et al., 2007). Modelling studies have been supportive of social distancing in a systematic review of modelling and epidemiological studies on social distancing in non-healthcare workplaces (Ahmed et al., 2018). Evidence is emerging on social distancing in the current COVID-19 pandemic, and it has been commented that the scientific basis and ethical considerations of such interventions must be taken into account (Lewnard & Lo, 2020). Based on a modelling study of the COVID-19 outbreak in Wuhan in China, Prem et al. say that physical distancing measures would be most effective if they are staggered and such interventions shall help to delay the epidemic peak (Prem et al., 2020).
The effects of social distancing as a public health measure in controlling epidemics are becoming increasingly known. Its effects on human societies are not as well understood though. Nor has it been seen how societal changes triggered by social distancing can affect public health. This essay describes how a protracted adherence to social distancing guidelines would affect the Indian society. Changes are expected in some of the prevalent cultural norms. Gender relations within the family are likely to change as also working patterns. Social distancing is likely to be stressful, especially for older adults. Human interaction based on digital technology is likely to increase. The implications for public health in India due to such changes are also discussed.
Changes in Cultural Norms
Personal space refers to an imaginary bubble considered to be a private region surrounding a person. It is the distance to be maintained while communicating with others (American Psychological Association, undated). Personal space differs from culture to culture. It is narrow in India. People in the country may stand close to one another in a queue without feeling offended. In such a context, the distance recommended for social distancing to prevent the spread of COVID-19 can be culturally alien, especially if there is low perceived threat from the disease. If people in India strictly adhere to the guidelines on social distancing, then there would be a change in the notion of the physical distance that constitutes personal space for individuals. It would become intrusive if people came closer, years of maintaining social distancing having resulted in such a change.
The notion of common good may also undergo a change in the Indian society. Common good ‘refers to those facilities-whether material, cultural or institutional-that the members of a community provide to all members in order to fulfill a relational obligation they all have to care for certain interests that they have in common’ (Stanford Encyclopedia of Philosophy, 2018). It may refer ‘either to the interests that members have in common or to the facilities that serve common interests’ (Stanford Encyclopedia of Philosophy, 2018). Roads, public hospitals, and public transportation as also civil liberties such as the freedom of speech are some examples of the common good. Traditionally, the Indian society was composed of communities which specialised in the provision of goods and services. They practised endogamy, that is, members of a community married among themselves. However, different communities were organically dependent on one another, the caste system being a prime example in this regard. (This is not to overlook the inequality that existed between the communities in such a social order and the institutionalised privileges/systematic discrimination faced by members of different communities). The changing economic and political systems in the country changed the relationship between communities from cooperation to competition. With the rise in market economy, members of different communities began competing for resources such as food and jobs. Electoral politics also changed the relationship between communities. Having members of one’s community as elected representatives meant protection and furthering of one’s interests. The notion of common good is compromised in such a context, where people view each other as competitors.
The announcement of a countrywide lockdown by the Indian government led to people crowding in shops to purchase essential commodities such as food items. Such crowding is illustrative of the prevalent notions of personal space as well as common good in the Indian society. Anxious that essential commodities will become scarce/unavailable, people thronged shops, competing with others for the goods. This has, nevertheless, attracted widespread condemnation from several quarters for violations of the guidelines on social distancing. Migrant workers crowded railway stations and bus stops to leave for their hometowns. They constitute the labour in a market economy that was disrupted by the pandemic. Home offered a sense of security at a time when there was uncertainty regarding work, wages and food. In the absence of public transportation, migrants walked hundreds of kilometres to reach their homes (Biswas, 2020). (There have been violations of the social distancing guidelines in other contexts in the country too. These include weddings and religious gatherings that have been attended by hundreds of people. Such violations have occurred due to prevailing cultural norms of what is appropriate on such occasions. Non-participation in such events can have negative social consequences including social ostracism).
The notion of common good is likely to change in the Indian society in the aftermath of COVID-19. This is because there have been concerted efforts by the governments, corporates and civil society actors to provide for food and other essential items during this period of crisis. There have been numerous collective and coordinated efforts to respond to it. The state government in Uttar Pradesh has made dry ration available to all till 30 June 2020. It would not be necessary to show any form of identity card to claim this ration (Gaur, 2020). Several state governments have set up community kitchens to feed the hungry and the homeless (Hindustan Times, 2020). Corporates have donated funds towards building health infrastructure and community kitchens (Economic Times, 2020, April 1; Financial Express, 2020). Several civil society initiatives have been instituted during this time to provide food to the hungry. Political parties and common citizens have set up community kitchens (Deccan Herald, 2020; Srivastava & Nagaraj, 2020). Members of women’s self-help groups are making face masks, running community kitchens, providing food to the elderly and the quarantined, and sensitising people about health and hygiene (World Bank, 2020). Food and other essential items as scarce commodities can be prized by competing parties. However, making these available to all who may need them is an effort at advancing the common good by different actors. It symbolises the prioritisation of common interests over personal profit or sectarian gain.
Effects on the Indian Family
The family is patriarchal across communities in India. Lineage is determined through the father (patriliny) and it is customary for the bride to relocate to her husband’s household (patrilocality). Men exercise the authority in the household and have control over resources such as property. Typically, they are the decision-makers too. The mean household size is smaller in urban India compared to its rural areas (Office of the Registrar General & Census Commissioner, undated a). Households in urban India tend to be nuclear (Singh, 2003). A couple and its unmarried children usually reside in such households and it is common for both the husband and the wife to be in paid work. However, there is gendered division of labour within the household, with women being primarily responsible for housework and childcare (Sourabh, 2007). Supporting them are cooks and maids, a feminised workforce that has become a staple in households across urban India.
Such support was abruptly interrupted during the series of countrywide lockdowns in India that ran into months. Due to strict stay-at-home orders, members of households were confined to their houses with no support received from outside people. Cooking, cleaning and childcare responsibilities began to be shared. There are media reports about husbands cooking and cleaning utensils (Borah, 2020). Apart from such reports, social media is rife with jokes about men having to cook food, clean utensils and mop floors. Gender roles in the household are being tweaked in favour of greater sharing of domestic responsibilities.
Will this be short lived? Some marital relationships may be reaffirmed as a result of sharing of domestic responsibilities. There is global evidence showing that sharing of housework leads to stability in marriage/cohabitation (Ruppanner et al., 2018). Unpaid housework may become more equitably distributed between men and women in households, especially in urban India. In view of the fragility of outside support, the socialisation of boys may begin to include learning of skills such as cooking and cleaning. Moreover, the Indian economy is expected to be hard hit by the pandemic. Further, social distancing norms are expected to be in place for some time. Households may dispense with the services of cooks and maids as a protective measure, as well as to tide over the effects of job loss and reduced pay.
Caregiving roles are gendered in the family with women being primarily responsible for taking care of the sick. Their traditional role as caregivers in the family (and other gendered roles) put them at particular risk of exposure to Ebola virus (Davies & Bennett, 2016). Women in Indian households may be similarly vulnerable. Staying at home has other effects too. Women are often trapped with abusers with little recourse to help. Violence against women and children (including intimate partner violence) has been observed to increase during crises and pandemics. Several countries have already reported increased incidents of violence against women and children in the current COVID-19 pandemic (Peterman et al., 2020). Based on literature, Peterman et al. identify nine main (direct and indirect) pathways linking pandemics with violence against women and children. The authors also suggest additional pathways based on limited or anecdotal evidence that are likely to affect smaller subgroups. As per the complaints received by the National Commission for Women in India, cases of gender-based violence have more than doubled in the country during the first week of the lockdown (Chandra, 2020).
Lockdown is an effective social distancing measure to break the chain of COVID-19 transmission. As a result of this pandemic-induced social isolation, there is likely to be increased consumption of electronic content and a change in the way people spend their time. Watching online videos is likely to increase by 60 per cent and watching TV shows or movies by 57 per cent (Figure1). Double digit increases were expected in the watching of linear TV, social media engagement, chatting, texting and playing video games also. This is indicative of the leisure time people have and the entertainment options they resort to during confinement. If flexibility in work timings or work from home is practised more widely in the aftermath of COVID-19, then such consumption of electronic content is likely to continue.
Maintaining social distancing would be a challenge in crowded localities such as slums. There were more than 13 million slum households as per the 2011 Census of India. About half a million of such households were dilapidated (Office of the Registrar General & Census Commissioner, undated b). Almost 2 million of the total slum households had two or more married couples residing in them (Office of the Registrar General & Census Commissioner, undated c). The poor are vulnerable even in normal circumstances, with the social determinants of health being particularly compromised. It is unrealistic to expect slum residents to maintain social distancing in crowded living conditions. Dharavi is a large slum located in Mumbai. It is densely populated, and the living conditions are squalid, increasing the risk of contracting infection for people living there. Not surprisingly, there has been an outbreak of COVID-19 cases in Dharavi.
Other effects of social distancing are anticipated in Indian families. The pandemic is causing stress in populations across the countries of the world (World Health Organization, 2020). The Centers for Disease Control and Prevention (CDC) says that ‘fear and anxiety about a disease can be overwhelming and cause strong emotions in adults and children’ (CDC, 2020d). Stigmatisation is especially common during disease outbreaks with fear and anxiety about a disease leading to social stigma. Such stigma can be towards people, places or things (CDC, 2020c). Healthcare workers may face ‘avoidance by their family or community owing to stigma or fear’ (World Health Organization, 2020). In an advisory titled ‘Minding our minds during the COVID-19’, the Indian government suggests ways to handle social isolation and emotional problems, among other issues. It recognises that there may be emotional issues after recovery, and a person may be subject to stigma. The advisory calls for recognition of mental health problems among family and friends. It also flags the issue that persons with a history of mental illness ‘may face newer challenges during self-isolation or COVID infection’ (Government of India, undated b).
Social distancing can be particularly stressful for older adults. Their physical dependency increases with age-induced debility. They increasingly rely on aids and human support for their routine chores such as bathing and eating (Barman & Mishra, 2020). Older adults, especially those in isolation and with cognitive decline/dementia, may become ‘more anxious, angry, stressed, agitated and withdrawn during the outbreak or while in quarantine’ (World Health Organization, 2020). Due to decreased immunity and body reserves, as well as comorbidities such as diabetes and hypertension, older adults are at a higher risk of COVID-19 infection (Government of India, undated c). Maintaining social distancing can be stressful for them, given their physical dependency and emotional vulnerability.
Changes at the Workplace
The workplace is expected to undergo transformative changes due to social distancing.
During the initial days of the outbreak in India, work from home was recommended for employees who could do so. Companies working in the Information Technology sector in the country were early adopters in this regard. As the disease spread in the country, work from home became a preferred practice for employers, even for those who had not exercised this choice earlier. The lockdowns made this unavoidable. As the Indian economy faces a crisis, organisations may look to rationalise their operations in order to be efficient and survive in the difficult times. Allowing employees to work from home is expected to be a favoured option in order to cut down on establishment costs, while enhancing productivity at the same time (Bhattacharyya & Verma, 2020).
Progress in digital technology has never been more evident than during these times of social distancing. Digital technology is being widely used and is likely to continue beyond the current spurt. Online learning platforms are being used by educational institutes ranging from primary schools to higher education centres such as universities. The purpose of such virtual classrooms is not only to transact curriculum but also to ‘exhibit care and build an effective relationship with the students’ (India Today, 2020). Though educational institutes (including training and coaching centres) were to remain closed during the lockdown period, they were ‘expected to maintain the academic schedule through online teaching’ (Government of India, 2020). Such a shift to online learning could mark a turning point for the industry, ushering in an increased usage of this format and changing habits in terms of how teachers teach and students learn.
Telemedicine is being encouraged. Patients can connect with medical professionals without leaving their homes, thereby ensuring the avoidance of non-essential travel to healthcare facilities. Guidelines for practising telemedicine have been issued (Board of Governors, 2020). It has given ‘a boost to the business of healthtech startups operating in the segment’ (Mandavia, 2020).
There will be changes at the workplace in other ways too. In a recent order issued by the Ministry of Home Affairs, Government of India, social distancing has been made mandatory while easing the lockdown. Standard Operating Procedures for social distancing have been laid down for ‘offices, workplace, factories and establishments’. These include staggered shifts, discouragement of gatherings or meetings of 10 or more people, and sitting ‘at least 6 feet away from others on job sites and in gatherings’. Violations shall attract penal provisions (Government of India, 2020). As a sign of things to come, workers in tea gardens in Assam have resumed work. Maintaining social distancing, as also using masks and sanitizers, has been adopted by them in the changed times (Livemint, 2020).
Implications for Public Health
The immediate and most recognised effect of social distancing on public health is its ability to control the spread of an epidemic. Epidemiologists are of the view that the spread of COVID-19 cannot be stopped. However, it can be slowed down considerably by adopting social distancing measures (Figure 2). By limiting human contact, the transmission rate can be reduced substantially, which in turn, increases the time taken for the cases to double.
With COVID-19 expected to last for years, and vaccines and drugs being currently unavailable, social distancing needs to be observed for a protracted time period. The widespread practice of telemedicine is expected to reduce geographical inequities in access to healthcare. The multiple changes brought about by large-scale adherence to social distancing guidelines have several other implications for public health in India. In particular, such changes shall impact the sociocultural determinants of human behaviour. The changed notion of personal space (and privacy) can improve current practices at healthcare facilities. Maintenance of privacy in such settings can be compromised in the country. Nagral comments that privacy is not observed while undergoing examination or tests, and information about the patient is not kept confidential. This is especially true in the case of socio-economically disadvantaged people (Nagral, 1995). A changed notion of personal space will raise the expectations of patients from their healthcare providers. The latter, on the other hand, will be more mindful of protecting the privacy of the patients. Similarly, maintaining distance between individuals while undertaking public health research (e.g., surveys on health) may be expected.
What will be the effect of the changing notion of common good on public health in India? Public health is rooted in the notion of common good. It is pitched to bring about positive changes at the population level. Public health gains are societal in nature, and not individuated stories of care and recovery. Practising social distancing is as much a measure to protect oneself from the virus as it is about protecting others from oneself. It is an activity that promotes the common good. It is a rare occasion when behavioural change in the population is so passionately invoked in countries across the world. Terms such as ‘do your part, stay apart’ and ‘social distancing’ are becoming ingrained in the popular imagination. Aberrations notwithstanding, it is the nudge to the collective to practise social distancing and its adherence by the people that shall boost the preventive aspects of public health.
The tweaking of gender roles in the household would be beneficial for women’s physical and mental health. However, this would be possible only if women and girls lead a life free from violence. The tweaked gender roles coupled with a violence-free life would aid women’s health-seeking behaviour too. Women experience role strain and have little leisure due to the multiple burdens of paid work, childcare and household responsibilities (Mishra, 2006). This affects their care-seeking behaviour. The tweaking of gender roles in the household is likely to offer them the time to seek care. Moreover, if work from home (or flexible working hours) becomes the new norm for many professions in the aftermath of COVID-19, men would be sharing household responsibilities. Even male involvement in women’s health may be expected to increase due to greater sensitisation brought about by years of sharing such responsibilities. It is likely to result in greater appreciation for the unpaid/underpaid household chores typically done by women and enhance the dignity accorded to such work.
Conclusion
Major events bring about changes in society. Social distancing measures are expected to be in place for a sustained period of time in order to limit the spread of COVID-19. Maintaining social distancing is likely to become habit forming, with its effects going well beyond limiting the spread of the disease. The promotion of social distancing at various places (e.g., offices, educational institutes) and in different ways is likely to make it customary in the Indian society. Human beings are social animals. During these challenging times, technology has made it possible for us to stay connected and receive healthcare in innovative ways in spite of practising social distancing. This makes the experience a different one than what would have been the case in earlier times.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.