REVIEW ARTICLE
SUETUGO, Isabela Moreira [1], CARVALHO, Paula Bavaresco [2]
SUETUGO, Isabela Moreira. CARVALHO, Paula Bavaresco. To what extent do Brazil and the world benefit from stricter isolation measures? Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 05, Ed. 08, Vol. 01, pp. 87-105. August 2020. ISSN: 2448-0959, Access link: https://www.nucleodoconhecimento.com.br/health/isolation-measures
SUMMARY
COVID-19 has brought several challenges around the world, one of which is the difficulty in defining effective strategies that can generate a reduction in the incidence of this pathology, so that we can have greater control over its transmission and lethality. Many countries have opted for non-pharmacological measures due to the fact that we do not yet have scientifically proven pharmacological therapies. Brazil presented many obstacles in prevention measures against this pathology, ranging from political conflicts between the federal, state and municipal levels, to the non-population’s reach. Very little is still known about this new virus, especially its epidemiological behavior, which further conflicts its control strategies. This review study aims to analyze the measures taken of social isolation in several countries, including Brazil, making a comparison between which would be the best choices. A research was carried out in the main portals of health studies, seeking recent evidence that could generate a discussion about the advantages and disadvantages of the strategies of the main world powers that generated studies on social isolation and total confinement of the population to the detriment of the reduction of cases of coronavirus. There is evidence that social isolation with total population confinement at the beginning of the outbreak is better efficient, although some authors have contrary opinions. However, we cannot let go of the political, social and economic problematization in the realization of this measure that still generates debates between the rulers, health professionals and the population.
Keywords: COVID-19, coronavirus, social isolation, lockdown.
INTRODUCTION
COVID-19 (Coronoavirus disease-19) is an emerging pathology that since its dissemination has caused damage to the population of several countries. It is characterized with a disease that mainly affects the respiratory system, causing fever and/or cough and respiratory difficulty, with 1/3 of patients evolving with Severe Acute Respiratory Syndrome. You may have other nonspecific symptoms such as myalgia, headache, mental confusion, chest pain, and diarrhea. The first cases arose in wuhan city in Hubei Province, China, in early December 2019. Only on January 7, 2020 was it identified as a new coronavirus, being named as 2019–nCov by the WHO (World Health Organization). The virus still has an unknown epidemiological behavior, since lethality rates appear to be very variability, being in Italy 9% and Germany 0.3%. However, it is known that there are many risk factors that can influence these rates, such as chronic obstructive pulmonary disease, diabetes, obesity and systemic arterial hypertension. On March 11, 2020 alone, who declared the global pandemic, with a confirmed worldwide count of 118,000 cases in 114 countries, with a death toll of 4,200. At the end of April the pandemic reached 213 countries with more than 3 million confirmed cases, showing the great impact that the disease has worldwide (WHO, 2020).
Brazil ranks second in the ranking of countries with the most confirmed cases in the world with more than 1.5 million cases, second only to the United States of America, which has more than 2.7 million cases. It is also noted from the graph provided by the University of Oxford that Brazil is followed respectively by India with another 1.1 million, Russia with more than 650,000 and South Africa with more than 270,000 cases, which shows a great distance in the number of new cases in Brazil compared as the world (ANNEX 1).
Still on the characteristics of this pathogen, it was evidenced that its dissemination occurs particularly by respiratory droplets. The virus lodges in the respiratory secretions of the infected individual who, when sneezing, coughing or talking, the droplets from that person’s airways can reach another person’s airway, contaminating them. Another form of transmission is through the surface of objects, touching a contaminated object and after having contact with nose, eyes or mouth. In addition, there is aerosol transmission after performing nebulization or orotracheal intubation procedures (VELASCO et al., 2020).
Due to the absence of prior immunity in the human population and vaccine against the pathogen, the number of cases increased dramatically. Within this perspective, epidemiologists proposed, as a way to prevent the spread of the virus, non-pharmacological interventions, imposing measures that could prevent the contagion of citizens, ranging from hand washing to closing borders with social isolation (GARCIA; DUARTE, 2020). The Pan American Health Organization (PAHO) issued a note on April 3, 2020, in favor of non-pharmacological measures. The note suggests that these measures may, in addition to flattening the epidemic curve, alleviate the collapse of health services, especially in intensive care units. Among the non-pharmacological measures we have total confinement (lockdown), selective social distancing and expanded social distancing, which are measures of distancing between people, in order to contain the transmission between them. According to Nakamura (2020, p.3)
The lockdown is the highest level of security and may be necessary in a situation of serious threat to the health system. During a full lockdown, all perimeter entrances are blocked by security professionals and no one is allowed in or out of the isolated perimeter. It differs from other measures of social distancing, such as expanded social distancing, known as quarantine, and selective social distancing, known as vertical isolation. The expanded social distancing is a measure of social distancing that is not limited to specific groups, requiring that all sectors of society remain in residence during the term of the decree of the measure by local managers. This measure restricts contact between people as much as possible. Selective social distancing is social distancing where only a few groups are isolated, and groups that are most at risk of developing the disease or those that may present a more severe condition, such as the elderly and people with chronic diseases (diabetes, heart diseases, etc.) are selected. or risk conditions such as obesity and risk pregnancy. People under 60 years of age can move freely if they are asymptomatic.
According to PAHO (2020), there are still measures such as isolation of people, which is the separation of patients with the disease aiming at non-transmission, and the quarantine of people, which restricts activities and separates non-sick people in order to avoid the appearance of new infected patients. The most drastic measures, such as home confinement, were indicated by PAHO in “selected segments”, such as for the elderly population, people at higher risk of fatal outcome, or the population in its entirety, when there are legal, administrative and sanctions contexts that allow this type of activity. This confinement can be done by establishing curfew measures or limiting the movement of people within a predefined perimeter, being allowed to leave only for medical purposes and household subsistence tasks.
However, these measures of social isolation and even total confinement of the population present many problems, such as deficits in the social structure and, mainly, economic of many countries, as brought in the update of the note of April 3, 2020 by PAHO that was launched on April 24, 2020. The update highlighted numerous questions on the part of the governments regarding the adoptances of “severe measures of social distancing and measures related to travel” and the document aimed to answer these doubts and guide the decision-making of the leaders that we will quote later in the discussion of the article.
On February 3, 2020, the epidemic was declared in Brazil, being considered an emergency in public health, and on February 6, 2020, Law No 13.979 was sanctioned, which determines the measures to combat the COVID-19 epidemic, in addition to assigning supposedly effective strategies of non-pharmacological interventions (GARCIA; DUARTE, 2020). However, Brazil, like other Latin countries, suffers many obstacles, such as the lack of awareness of the population about isolation, lack of infrastructure in the country’s health units, a high social unevenness and difficulties in tracing a linearity in its measures to cope with the disease, since each state and city had different postures regarding the pandemic. Many questions occurred about the legality of carrying out a mandatory confinement, which may infringe the right to come and go of the human being (BEZERRA et al., 2020). This whole context generates a great discussion about the real advantages in performing such severe activities.
GOALS
The aim of this study was to analyze the advantages and disadvantages of lockdown and compare the strategies carried out worldwide and nationally. Aiming at the best current analysis on prevention strategies and reduction of the incidence rate in the world.
METHODOLOGY
For the present study, 26 sources were searched among articles in Portuguese and English, books and sources of epidemiological data worldwide and nationally, using national and international databases: MEDLINE/PubMed, Scielo, The Lancet, Natural Medicine, search site of the World Health Organization and the Google Academic search site. The keywords used for the selection of articles were: “lockdown”; “covid-19”; “coronavirus; ” social isolation”; “epidemic”; and “control”.
After a bibliographic survey, an exploratory reading was made by two researchers of the selected articles in the area of collective and epidemiological health to identify those of possible interest for the construction of the work, based on the choices of the most recent articles and that deal with the theme in order to be scientifically proven by real methods. Then, a selective and in-depth reading was performed identifying those of content that really relevant to the preparation of this review.
Discussion
We looked for articles that could highlight the advantages and disadvantages of stricter confinement such as lockdown. A debate promoted by the site The BMJ (2020) and even though there are many factors that indicate the lockdown as a good alternative, there are authors who differ from this opinion. The research shows that, at first, it is a good strategy, but in prolonged blockades there is a relevant economic deficit, generating high unemployment rates, for example (TODA MATÉRIA, 2020). Martin et al. (2020) highlights the serious sharp losses of the world economy due to measures of social distancing. It cites a World Bank report showing that 11 million people could fall below the poverty line in East Asia and the Pacific, and highlight the drop in gross domestic product (GDP) of the world’s largest power, the United States of America, by 4.8 percent in the first quarter of 2020. The article also warns about the care that countries must demonstrate, such as large-scale unemployment, increased need for public health resources, high global poverty rate and long time for economic recovery in underdeveloped countries.
In addition to the economic challenges, many health problems have also arisen with the performance of a blockade. An article published by The Lancet (2020) on July 4, 2020, demonstrated disappointment on the part of the authors in the dichotomy that exists in the idea of trade closure and social isolation. The article states that UNICEF and the authors believe that blockades can kill people through the interruption of health services and deprivation of livelihoods, stating that populations living on the margins of the economy benefit little from the blockade, and children are the most exposed to such vulnerability. In the developing countries of the African continent, much difficulty in communication with the population has been noted, which occurs since the Ebola and HIV epidemic and remains to this day, due to a heterogeneity of the population ethnicities, cultures and habits (JOHNSON and GORONGA, 2020). Regarding children and adolescents, the article by Knopf (2020), published in the Journal of the American Academy of Child and Adolescent Psychiatry, there is a greater possibility of an increase in psychiatric disorders in children and adolescents during the quarantine period, since the closure of schools generated a social isolation of young people, leaving them lonelier. In addition, it was also evidenced by the multinational article by Roso et al. (2020), which analyzed adolescents in social isolation in Italy, Spain, Chile, Colombia and Brazil, an increase in the poor eating habits of adolescents, increasing the subsequent risk of metabolic and degenerative diseases.
In Brazil, several challenges have emerged to be overcome, as in other countries, since the lack of schooling of the population, unemployment problems and psychological stress, as evidenced in the study by Garcia and Duarte (2020). The Brazilian federal government, with its policy focused on the economy, spread the idea of a Brazil that cannot stop, encouraging the maintenance of the flow of people on the streets and following trade activities. This discourse came in counterpoint to the measures taken, especially in some federative entities such as São Paulo, epicenter of the disease, with stricter social isolation. These divergences of dialogues and political conflicts further worsened the pandemic, being aggravated by a political dispute and the appearance of fake news that were disseminated by the media and social networks. This made it very difficult for the population to be affected by isolation and distancing, directly affecting compliance by the population (AQUINO, 2020). Moreover, there was wide discussion whether the lockdown would have legally constituted support, since it may infringe the citizen’s right to come and go. As mentioned in Nakamura’s article (2020) the lockdown should be seen as an instrument to protect people’s health and life. However, it limits intensely a fundamental right of locomotion provided for in Article 5, item XV of the Constitution in the following terms: “it is free to locomotion in the national territory in peacetime, and any person, under the law, enters, remains or leaves with his property”. Freedom of movement covers the freedom of movement itself and that of movement. According to José Afonso da Silva’s lesson “the freedom of movement in the national territory in peacetime, contains the right to come and go (travel and migrate) and to stay and stay, without authorization”. The right of movement, according to José Afonso da Silva, “consists of the faculty of moving from one point to another, through a public road affected to public use”.
However, the disadvantages pointed out above are counterbalanced by other solutions. Even Martin et al.’s article. (2020), which presents extremely negative points on confinement, shows that COVID-19 without any protection would lead to a massive economic shock in the system and, in fact, there are ways to avoid worsening the economic situation, as was the implementation of the CARES Act (Law on Aid to Coronavirus, Aid and Economic Security) sanctioned in the U.S. on March 27, 2020 by President Trump , helping 90% of the financially unemployed. Moreover, all the articles cited in the paragraphs above this discussion do not denote certainty in the data, making it clear that they would be “possibilities”.
We can see articles that point to other positive points of the lockdown in countries that have adhered to the measure. In Italy and Spain, countries that were severely affected by the disease, it was evidenced that, after confinement, there was a great reduction in the incidence of the disease, leading to a real flattening in the epidemiological curve of these countries (TOBIAS, 2020). In particular in Italy, there is evidence that contact restrictions had an effect on the nine-day incidence decrease in the most prevalent sites, with effects on average 14 to 18 days in the country (VINCETI et al., 2020). In other European countries, Greece, even though it has not yet stabilized economically, was one of the countries that adhered to the lockdown that stood out best, achieved a flattening of the new case curve without further aggravating the unstable situation of the country’s health system and generating large economic deficits. Moreover, it was only after Norway and Finland in the lowest number of deaths per million inhabitants, due to the massive investment in the health system that the latter two made (MORIS; SCHIZAS, 2020). Another study conducted in the United Kingdom, a country also very affected by COVID-19, calculated that there was a high level of acceptance of the isolation measures taken by the government and resulted in a 74% decrease in the total number of physical, non-physical, contacts by people, and this contact restriction will lead to a reduction in incidence, even if not immediate (JAVIS et al., 2020).
In relation to the Asian continent, at the epicenter of the pandemic in Wuhan, there was a decrease in the exponential growth of new cases. However, outside the blocking area the incidence continued to increase, attributing to the blockade a positive signal to delay the contagion of new individuals (LAU et al., 2020). It was possible to reaffirm that the loosening of preventive measures generated an increase of 71.8% in the number of new cases, according to the article by Hussein et al. (2020), with the loosening of measures in Israel, which, even though it was not on the same continent, evolved with the same history. Like an underdeveloped country, in an article published by the Journal of Infections in Developed Countries, India performed a prolonged blockade of 19 days, followed by blockades of less than 14 days, with certain relaxations, and managed to reduce relatively new cases and mortality per million inhabitants (KRISHAN and KANCHAN, 2020). Another article from India showed, through a mathematical methodology, that there were really positive effects on confinements and, even suggests, that the blockade be done 21 days throughout the country and an extension of another 21 days would improve the interruption in chain transmission (AMBIKAPATHY and KRISHNAMURTHY, 2020).
Still talking about developing countries, the African continent has already faced an epidemic of a little-known virus at the time, Ebola, about 6 years ago and still faces an HIV epidemic. These experiences have brought many lessons to the countries of this continent, such as Zimbabwe and Sierra Leone, which required high investments in raising awareness of the population so that prevention measures would be more effective and bring less harm to those countries already living in a situation of social and economic marginality. This study also showed that it is possible to carry out strategies that bring the population closer to a full awareness of the need for prevention, amid the lack of resources of these countries (JOHNSON and GORONGA, 2020).
When it comes to mental health problems, Matias et al.’s article. (2020) does not deny that isolation has harmful effects on mental health, however, there are strategies that can improve these damages, such as physical activity, even performed in social isolation, which would also lead to a decrease in cardiovascular risk factors. In addition, the study by Hoffman et al. (2020), demonstrates in a scientific way that we can propose three different simple strategies to alleviate social, psychological and economic burdens throughout the pandemic, such as: search for similarity (individuals should seek similarities in contacts that have subjects and characteristics that attract their attention, as a way of restructuring a network of contacts), strengthening interactions in communities (individuals should interact in a triadic way , making your contact the same as that of your friend, so that this strengthens a dialogue between this group), and repeated interaction with the same people to create bubbles (these narrow networks provide a smaller contact with individuals, it would be indicated for elderly people or with pre-existing risk factors, so that they limit contact with people who may possibly transmit the disease).
In Brazil, according to Datafolha, which interviewed a sample of 1,511 people in April 2020 in several states, 76% of the population was favorable to maintainsocial distancing, proving that the population is interested in non-pharmacological measures (AQUINO et al., 2020). In addition, according to the data collected by the State Health Secretariats, the incidence curve is still increasing (APPENDIX 2), but in the state of São Paulo, there was a slight flattening of the curve in recent weeks, which may or may not refer to the isolation made by the government, even with the divergences of conducts in relation to the federal government.
Still on the confinement and the questions that arose about his legal permission in Brazil, Nakamura’s article (2020, p.5) says that:
The right to locomotion can be restricted even in peacetime, provided that there is another fundamental right to be protected by implementing a measure restricting the locomotion of people, such as to prevent the expansion of a pandemic. According to the opinion of the Supreme Federal Court, “there is no absolute right to freedom to come and go (CF, Art. 5, XV) and, therefore, there are situations in which it is necessary to consider the conflicting interests in the assessment of the specific case13” […] There is the so-called “health police”, founded on item II of Art. 200 of the Federal Constitution, which must be exercised by the Union , States, Federal District and Municipalities, due to Art. 23, II, of the Federal Constitution. If, due to the stage of the pandemic, based on proven reasons in technical studies, the enactment of the lockdown is necessary, as the most appropriate and efficient health police measure, states and municipalities may decree it. If the stage of the epidemic justifying the most restrictive measure is contained within the territory of a municipality, it shall order the lockdown; if it has exceeded the scope of a municipality, the State shall order the lockdown; and, finally, if it has exceeded the scope of a State, the Union must order the lockdown.
Thus, it can be concluded that even in hurting the right to come and go of the citizen, it is still the duty of the State to take care of his health, and the lockdown can be decreed. Also, in the considerations given by PAHO on social distancing and travel restrictions, it has been suggested that this confinement be done with applications of legal tools, creating administrative measures that can sanction legal support for such attitude, evaluating the legal adequacy
CONCLUSION
The disease, because it is emerging and rapidly expanding, brings great difficulties in delinusing statistical data, preventing and delaying many prevention processes. Worldwide, the disease has become aggravating in most countries and has had drastic effects, especially on the economy. There have been many differences in the way isolation between countries is made. This made it even more difficult to draw up effective and safe plans for effective confinement.
However, many countries agree that the best strategy is non-pharmacological measures, mainly due to the lack of specific treatment and effective vaccines. Of course, we can not help but talk about the health problems that isolation causes in society, but we have been able to show, in several articles, that the education of the community associated with the investment and support to the health of the population, by the public power, can be effective ways avoiding greater damage caused by coronavirus and social distancing. These strategies provide greater support on the part of the rulers to the acceptance of a stricter strategy of isolation, since even with the economic losses, there is no way to dispute that social confinement decreases the incidence curve of the disease.
In Brazil, the country’s internal challenges, such as political divergences between municipal, state and federal levels, further compromise the control of the incidence rate of the disease. However, we cannot fail to note that other developing countries as populous as Brazil, such as India and China, have benefited from the lockdown. India is a current example, the Indian country managed to stay with fewer accumulated cases than Brazil, occupying the third position in the ranking, even with a population of 1.3 billion inhabitants compared to the 209.5 million inhabitants that Brazil has, according to the World Bank. Even if there are cases of underreporting, we can still highlight the difference between these two countries in the new case data.
In conclusion, in many countries it was essential to take strict strategies of social isolation, for the success in controlling this coronavirus pandemic. However, the lockdown should be planned and executed in a very well planned manner, considering the demographic and epidemiological aspect. There is evidence in the research that countries that were most successful were those that planned in advance and sought to avoid internal conflicts, such as Norway (high investment in health) and African countries (high investment in strategies that bring the population closer to acceptance of preventive measures). It is also clear that there are other factors that interfere with the incidence rate, but preventing transmission with non-pharmacological measures proves to be an effective low-cost strategy for the government (which even allows marginalized countries to adhere to the practice). And until there are no consistent and specific pharmacological forms that can decrease the incidence of the disease, this is a strategy that can be followed by several countries.
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ANNEXES
ANNEX 1
ANNEX 2
[1] Medical student.
[2] Medical school graduate.
Sent: July, 2020.
Approved: August, 2020.
