Public Spitting During Pandemic Times in India

Abstract

Traditionally the act of public spitting has been a putative “socio-cultural problem” in India. With the growing intensity of COVID-19 pandemic in India, it is of a predominant public health concern as evidence indicates sputum to be the potential reservoir of COVID-19 virus particles which could be easily transmitted. Despite being a significant public health issue, which is also linked to several other communicable diseases most notably tuberculosis (apart from COVID-19), this indiscriminate behavior has not received the due policy attention warranted. National and sub-national government enforcements and community level mass prudence to control this issue have been significantly dismal. Therefore, we aim to propose policy recommendations for short-term and long-term actions to prioritize this issue. The commentary advocates for immediate attention from national level policymakers and public health agencies to collectively respond to this issue and prevent (mitigate) any additional public health sufferings arising from this. Keywords: Public spitting, COVID-19, transmission, policy, India, smokeless tobacco.

The act of spitting is a potential source of transmission of many infectious (communicable) diseases. ¹ Transmission of COVID-19 is not directly attributed to spitting, but its potential role cannot be ruled out. ² There has been comparatively a reduced focus on the health risks associated with public spitting even during the ongoing pandemic. Although many states within India introduced penalties for public spitting during the pandemic, the enforcement has been limited. Moreover, there has hardly been any significant community level mass prudence on this. Even with a handful of published literature and cautioning media reports across the country in hindsight, the overall nationwide policy response to this has been egregiously dismal. During the catastrophic second wave of COVID-19 in India, the urgency to re-focus on this important public health issue is even more relevant now. ³ Traditionally the act of public spitting has been a putative “socio-cultural problem” in India. The indiscriminate behavior is perceptible in every nook and corner of the country and hence it is perceived as a socially acceptable phenomenon. Public spitting was a forgotten problem in India until it has been rediscovered lately after the onset of COVID-19. Despite being a significant public health issue linked to several other fatal infectious diseases, most notably tuberculosis (TB), this problem has not received the due policy attention warranted. Even within the ambit of the recent scheme like the ‘Swachh Bharat (Clean India)’ Mission, spitting remained a low priority. ⁴

In urban India, the problem of spitting is more pronounced as the visibility and media coverage are comparatively higher than in peri-urban and rural areas. Dirty red colored stains (‘paan stains’) which are commonly discernable on the sidewalls of the streets, at the entrance of public surface trains, premises of metro railways, and public bus stops are unambiguous examples of sheer negligence of this issue. Smokeless tobacco (ST) uses and public spiting is often ascribed as an act by people from low socio-economic strata, and to certain occupational categories such as rickshaw pullers, taxi, and auto drivers. But the habit is not entirely restricted to the one section of the society. These habits are also commonly observed among people in the higher social class. According to the Global Adult Tobacco survey 2017, approximately 200 million adults consume ST in India accounting for 70% of the total global ST related disease burden. ⁵ Despite a considerable reduction in the prevalence of ST usage (17% relative decline in 2010-2017), different types and forms of ST products are extensively consumed (double that of smoking; 10.7%) across various regions of India with prevalence being highest among the adult males within age group 30-39 (Table 1).^6,7 Chewing the ST products and keeping them inside the mouth for a certain period (the usual practice) promptly produces a strong and irresistible urge to spit.

Table 1.

Prevalence of Smokeless Tobacco use Among Male and Female by Their Background Characteristics in India, 2015-2016.

BACKGROUND CHARACTERISTICS	MALE		FEMALE
	PREVALENCE (%)	TOTAL (N)	PREVALENCE (%)	TOTAL (N)
Age
15-19	13.5	18,740	1.3	1,21,552
20-29	28.7	32,795	3.5	2,38,008
30-39	35.9	28,374	6.9	1,87,659
40-49	33.1	23,501	10.2	1,52,467
50+	30.5	8711	-	-
Place of residence
Urban	23.1	42,953	3.7	2,42,225
Rural	32.7	69,169	6.4	4,57,461
Caste
Scheduled caste	30.8	22,139	6.2	1,42,619
Scheduled tribe	42.3	9872	13.6	64,144
OBC	28.3	48,841	4.0	3,03,837
General	25.6	26,279	4.2	1,57,774
Religion
Hindu	30.0	91,390	5.3	5,63,739
Muslim	27.0	14,790	6.2	96,461
Others	19.8	5942	5.9	39,486
Education
No education	43.2	14,590	11.2	1,92,135
Primary	41.7	14,091	8.2	87,233
Secondary	27.8	64,010	2.7	3,31,037
Higher	13.5	19,431	0.6	89,281
Wealth quintile
Poorest	48.8	16,440	11	1,24,054
Poorer	38.1	20,904	8.1	1,36,900
Middle	28.9	23,687	5.0	1,43,814
Richer	22.7	24,976	3.0	1,47,978
Richest	15.4	26,114	1.3	1,46,939
Occupation
Not working	13.5	24,623	4.1	84,428
Professional/technical/managerial	15.1	7277	1.4	3516
Clerical/sales/service	26.5	20,914	8.7	6405
Agriculture	37.3	30,202	10.1	17,717
Skilled/unskilled manual	39.0	28,911	9.9	7592
Media exposure
No	47.3	8487	9.3	1,29,980
Any exposure	28.7	95,498	4.7	5,54,907
Full exposure	14.2	8137	1.1	14,799
Total	29.0	1,12,122	5.5	6,99,686

Note: Percentages and numbers are weighted. Cases may not be equal due to missing values. Source: NFHS-4, 2015-2016. ⁷

The act of spitting is becoming a predominant public health concern in the light of ongoing pandemic as evidence indicates sputum (spat out from the disease carriers) being one of the potential reservoirs of COVID-19 virus. ¹ The virus could potentially be transmitted from the sputum after prolonged use of ST, thus increasing susceptibility of transmission of disease. This unsanitary act is not a new threat in the nation’s history of public health emergencies. It was of colossal concern in the early 19th century colonial India when TB was ravaging through the country (and worldwide). Several public health experts and social scientists then came to the forefront recommending a ban on the manufacture and public sale of ST products and penalizing spitting. While many developed countries majorly succeeded in impeding the vile practice in the late 19th century, India significantly lagged. The anti-spitting regulatory laws and declarations in the country were easily circumvented and forgotten till date. ⁸ The case is no different in the 21st century COVID-19 pandemic. The advent of pandemic had galvanized the central agency Indian Council of Medical Research (ICMR) to put forth a nation-wide mass appeal to abstain from ST consumption and public spitting in April 2020. ⁹ Post facto, the Ministry of Health and Family Welfare, Government of India, had issued special ordinances leveraging additional authoritative power to sub-national bureaucrats on nation-wide cessation of sale of ST products and prohibition of spitting in public spaces with strict penalization. After initial responses by the national authorities, until May 2020, altogether 22 Indian states, six union territories and more than 150 districts have proactively imposed strict regulatory bans precluding the use of ST products and prohibiting spitting in open public places. This act is made as a punishable offence with state-specific monetary penalty (For example, Brihan Mumbai Municipal Corporation imposed a Rs. 1000 or 13.38 USD penalty) and indictment under Indian Penal code provisions. However, lax enforcement, sub-optimal monitoring, and lack of robust evaluation pose significant implementation challenges for such legislation.

Until now, India’s response to address the issue of spitting has been limited. The rampant spread of the disease and with the predisposed disproportionate high burden of ST usage among the marginalized section (Table 1) and across low literacy states, (Supplementary Material), it is pre-emptive to focus on an inclusive and targeted intervention rather than a uniform blanket approach. ⁷ The recognition and urgent response to this act is imperative to prevent any additional (preventable/avoidable) human sufferings arising from this. Considering the negligence of this issue in the public health fraternity and lack of large-scale epidemiological studies on estimating the nation-wide prevalence of spitting, it is hard to measure the habit in particular groups of population (based on socio-demographic data). Going forward, we reason acute “information asymmetry” and insufficient “political will” as the two pivotal and foundational challenges in prioritising this pressing threat. Hence, we aim to propose policy recommendations for short-term and long-term actions to sustainably overcome the identified challenges. These policy recommendations aim to supplement the already existing efforts by the national government.

Short-term recommendations

Aggressive “anti-spitting” and “anti-ST consumption” awareness campaigns by the local council members. Messages should clearly dominate on the health risks of ST consumption and associated health hazards (transmission of COVID-19) of spitting.

Making ‘spitting’ a punishable offence with monetary fine and detention under the National Disaster Management Act (s).

Strong vigilance should be deployed in the major metropolitan cities; empowering authorities to take appropriate indictment action against violation of rules.

Local council members partnering with community clinicians and pharmacists may consider circulating accurate risks related information through pamphlet distribution and use of posters in major public spaces (hospitals, public transports).

Long-term recommendations

Formulate a national policy on ST with provision for restricted use.

Consider additional taxation on ST products.

Public health agencies should prioritise spitting in national programs and policies. Include spitting as 1 of the major components in Swachh Bharat Mission.

Introduce anti-spitting etiquette in school education for early behaviour change.

Effective long-term investment in large-scale sustainable community level health behavior changes interventions. Since there is a profound disparity in the level of literacy across the social strata and education being the most important social determinant in ST addiction (prevalence is higher among people with no formal education: Table 1), ⁷ it is essential to incorporate the health literacy domain to enhance collective awareness and knowledge.

Introduce stringent anti-spitting policies in privately owned public-places, like malls, markets, and theatres. Fix responsibilities on owners.

Empower local bodies of volunteer groups (youth association, corporate, business, religious, and student groups) to ensure appropriate implementation of anti-spitting drives.

Supplemental Material

sj-pdf-1-tui-10.1177_1179173X211036668 ’ Supplemental Material for Public Spitting During Pandemic Times in India

Supplemental Material, sj-pdf-1-tui-10.1177_1179173X211036668 for Public Spitting During Pandemic Times in India by Ria Saha, Vikash R. Keshri, Bal Govind Chauhan and Suresh Jungari in Tobacco Use Insights