The College of Community Physicians of Sri Lanka (CCPSL) on Friday submitted a scientific exit strategy to President Gotabaya Rajapaksa for the COVID-19 affected Colombo Municipality area, which the most densely populated and economically important area in the island nation.
Colombo City Profile:
Colombo city is the economic hub of the country. It is the most populous city in Sri Lanka, with 650,000 –750,000 people living within the city limits. This is also added with a 500,000 daily floating population. People of Colombo City are from a multi-religious, multi-ethnic and multi-cultural background, representing a mix of several ethnic groups, mainly Sinhalese, Sri Lankan Tamils and Sri Lankan Moor.The City covers an area of 37 sq. km divided into six Districts. The Districts are further divided into 47 Colombo Municipal Council (CMC) Wards for its administrative purpose.
District 1 Colombo North; 2. District 2A Colombo Central; 3. District 2B Colombo Central; 4. District 3 Borella; 5. District 4 Colombo East; 6. District 5 Colombo West.
The latest coronavirus disease 2019 (COVID-19) data as per 24th April 2020 indicate that 91 out of 334 confirmed cases are from the Municipality area. Considering the uniqueness of Colombo as the commercial capital of Sri Lanka and the urgency in establishing normalcy, an exit strategy unique to Colombo Municipality area is indispensable.
However, at the same time, the fact that Colombo Municipality area is the worst-hit geographical area due to COVID-19 epidemic should be taken into consideration.
The key objectives are; 1. Maintaining a low case load; 2. Returning to near normal public life; 3. Economic recovery.
Nagalagam Street and Gunasenghepura, from which cases were reported previously, are currently “cleared” of cases. The case no. 21 was reported from Bandaranayake Mawatha on 16th April 2020. This is a typical “watta” found within a CMC ward and is located in a 16–18 perch geographical area with 230 people living in 62 houses. A sudden death of a 37 year old male has been reported from the same locality on 27th March 2020. RT-PCR testings performed on selected people in Bandaranayake Mawatha resulted in 81 cases and the adjacent 146 Watta has found 64 cases. In Princegate, all the samples tested were negative.
The above information gives an idea of the behavioral pattern of people in specific locations within a CMC Ward, such as in “watta” and the impact on the spread of the disease. Therefore, in addition to the caseload, it is essential to study the scatter of the households (families) and properties of people within Colombo Municipality area limits.
Properties within the city:
Residential Properties – 106,068; Commercial Properties – 35,604; Government Properties – 10,158; Exempted Properties – 3,671. Total Number of Properties – 155,501
High density low-income clusters (‘Watta’):
The average population density of Colombo Municipality area is 172 people per hectare (Department of Census and Statistics, 2001). However, high-risk pockets for COVID-19, similar to Bandaranayake Mawatha located within some CMC Wards, show higher densities such as 974 people per hectare. The highest population density is in Colombo North, which is predominantly a low-income residential area.
Half of the population of Colombo Municipality area has been living for many years in low income settlements, such as ‘watta’. The 2001 Survey carried out by the Colombo MC and SEVANATHA has identified a total of 77,612 families living in 1,614 low-income settlements in the city.
A unique character of these settlements was that they are relatively smaller in size. Further, 74% of them have fewer than 50 housing units while the larger settlements with more than 500 units account for about 0.7% of the total low-income settlements in Colombo.
In such high-density low-income clusters, nearly 60% of families have 5 to 7 members, while 8% of the households have more than 10 members per unit. Twenty per cent of housing units have more than 2 families. Often, when children marry, they too settle down in their parents’ house. Some families have rented out part of their house to earn an additional income.
Less-density high risk clusters
In addition to the typical high-density low-income settlements, there a Less-density high risk clusters. In addition to the typical high-density low-income settlements, there are clusters smaller in size confined to a few streets in some CMC Wards. And also there are populations in urban new settlements. Flats, mostly in Modara, Maligawatta, Dematagoda, Bluemendhal, Wanathamulla, Ingurukade and Slave Island area. The socio-cultural contexts and health behavior of these communities may also be different from other areas in the city.
Economic Implications of the low income populations
The city needs services of the people living in low income settlements for the proper functioning of various sectors of the urban economy. About 45% of the income-earning household members engage in unskilled employment activities (waged laborers, CMC garbage collectors, road cleaners, helpers, etc.).About 9% of families do not have any source of regular income. As such, lack of a regular source of income is a problem for about 54% of urban poor families.
Situation in Colombo as per WHO criteria:
1.Disease transmission is under control: Stage 3 b ;
Health systems are able to “detect, test, isolate and treat every case and trace every contact: Yes
Hot spot risks are minimized in vulnerable places: Yes
Schools, workplaces and other essential places have established preventive measures:
Guidelines formulated. Schools not started: Not yet
The risk of importing new cases “can be managed”: Yes
Communities are fully educated, engaged and empowered to live under a new normal: Not sure.
Disease transmission is under control
The Colombo district, including Colombo Municipality area, has witnessed an increase in the confirmed cases during the past week. However, it is apparent that the stage of the epidemic is shifting from the level of family clusters to village clusters. But health systems are able to “detect, test, isolate and treat every case and trace every contact.”
The Colombo Municipality area has the highest population density and has the highest movements of the people. A well-coordinated mechanism is essential in tracing not only cases and contacts, but also to capture possible community transmission.
Specifically, active case detection in CMC wards with lower socio-economic families should be continuously carried out. In addition, they should be targeted for testing at every given opportunity, such as when they report to work related to services (e.g. CMC labourers) and commercial/ business premises (e.g. manual labourers) within CMC sector. Currently, there is active surveillance conducted by the CMC health authrorities to detect infected persons in these high risk areas for COVID-19.
Categorization of the CMC wards as High Risk, Moderate Risk and Low Risk should be worked out based on the following parameters:
Number of cases reported within the last 28 days;
Extent of the primary / secondary contact load within last 28 days;
Geographical scatter of the households / families within a CMC Ward (Presence of “Watta” communities or other less density high-risk clusters);
Judgment on the compliance of the resident population with epidemic control measures.
In addition to the above, following aspects should also be considered: 1. Pregnant women / Persons with chronic illnesses; 2. Age over 65 years population; 3. Skilled / unskilled work force in each CMC ward; 4. Location of essential services / industries within a CMC ward.
Within each of the areas according to their identified risk profile, the withdrawal of curfew / implemented measures / restrictions needs to be carried out in phases in a staggered manner, while ensuring the continuity of interventions carried out so far to contain the epidemic.
Exit Strategy for three categories:
Stringent restrictions in high risk areas
Moderate restrictions in moderate risk areas
Relaxed restrictions in low risk areas
The optimal operationalizing of the strategy will also need rigorous inputs of real-time epidemiological geo-spatial data originating from ward level. Further, the exit strategy should be time-bound and requires change depending on the emerging local epidemic data and will be revised by a team of multidisciplinary experts when appropriate.
Generic considerations (irrespective of the risk):
Following services should continue irrespective of the risk level or the geographical area:
Key essential services: Health / Transport / Water / Electricity / Gas / Postal / Petroleum / Telecommunication / Harbour/ Vehicle breakdown services /Road maintenance / Irrigation; 2. Essential industries (non-crowding): farming, fisheries, construction sites; 3. Selected market places / industries will be opened; 4. Control of daily floating population – This should be addressed by a specific mechanism with restrictions enforced on the presence of minimal staff working at essential services / government and private offices.
STRINGENT Restrictions for High Risk Areas:
Lockdown status 24 hour curfew will be enforced. If the ward includes mainly highly dense lower socio-economic families, they will be shifted to quarantined centers based on the judgment on their health behavior. Other families will remain in their houses under strict supervision of Police and Armed Forces.
Travel Inbound or outbound travel will not be allowed, unless for a specific humane reason. Other vehicular movement allowed without stoppage, if a main road is crossing the ward or if a ward is along a main road.
Personal level measures including hand-washing, respiratory etiquette and social distancing should be practised. No private gatherings for any purpose, no religious congregations and all places of worship shall remain closed. Transport: No public or private transport allowed. All offices government / private remain closed. Home delivery services to continue and to be more strengthened. Schools / Other academic institutes will remain closed. Small Businesses will remain closed. Banks should operate mostly via ATM, online or mobile services. No physical client services offered. Carefully selected industries will be allowed to function with 50% workforce.
Modified 24 hour curfew will be enforced. Families will remain in their houses under strict supervision of Police and Armed Forces. Travel In bound or outbound travel–not allowed unless there is a specific humanitarian reason. Personal level measures including hand-washing, respiratory etiquette, and social distancing should be practiced. Only one person per house will be allowed outside the house premises at a time for a specific purpose. A token system should be introduced. Pregnant women should remain at home but allowed to attend routine clinics. Other vulnerable groups (persons above 65 years / patients with chronic illnesses are NOT permitted to move outside the house unless for medical reasons. They should obtain special passes if needed or may use the clinic record as a pass.
No private gathering for any purpose more than five persons, no religious congregations and all places of worship shall remain closed.Attendance at weddings and funerals should be restricted to 10 persons. No public or private transport allowed. All offices government / private remain closed. All pharmacies / General Practice / Medical Centers are allowed to open and should follow guidelines issued by Ministry of Health & College of GPs. Food & Groceries Home delivery services to continue and to be more strengthened. Schools / Other academic institutes all remain closed. Banks Should operate mostly online or mobile services.
Bank client services should be started with 2 sessions, 7.00 am – 12.00 N 12.30 N – 5.30 pm. Services offered once per week per customer. Different work hours may be introduced to reduce overcrowding in public transport. Daily wage-dependent employees are allowed with specific restrictions posed to employers on social distancing and basic hygienic measures. Carefully selected industries will be allowed to function with 50% workforce.
More Relaxed Restrictions:
These will be applicable to “Low risk” areas. The curfew will be lifted day time. Supervision by police and Armed Forces will continue. No restrictions on inbound or outbound travel. Personal level measures including hand-washing, respiratory etiquette, and social distancing should be practiced. No restrictions on moving outside the house premises, but “stay home” promoted. Pregnant women should remain at home but allowed to attend routine clinics.
Other vulnerable groups (persons above 65 years / patients with chronic illnesses are permitted to move outside the house for a specific purpose for a limited time period. No private gathering for any purpose more than 10 persons. Religious congregations and all places of worship will be opened for only 10 people at a time. Weddings and funerals should be conducted with minimal participants, complying with hygienic practices and maintaining social distancing.
Public transport (CTB / Private / Train) allowed for travel with 50% seating capacity within the area. Private vehicles / Taxi are allowed with only 2 passengers. Three wheelers / Motorcycles / Bicycles can carry only one passenger. All healthcare services (government and private) should be resumed with triage systems to care for patients with fever.
All workplaces (Government / Private) in the geographical area to resume work with 2 sessions 50% employees per session (one group per week of every other day:; 7.00 am – 12.00 N 12.30 N – 5.30 pm. Different work hours may be introduced to reduce overcrowding in public transport. Food & Groceries home delivery services to continue and to be more strengthened. Small groceries / shops allowed to open with minimal crowding.Larger food / grocery outlets (Supermarkets) –restricted entrance with one token card per family for a designated outlet / Token valid once per week for 1 hour. The catchment area and the catering population should be considered.
Economic Centers and other large scale wholesale food markets are kept open in compliance with safety health measures. Schools / Other academic institutes All remain closed. Non-grocery supermarkets, malls, Hardware and shops selling other merchandise like jewelry, textiles and electronics will be opened. Eating places, restaurants, tea shops, bakery will be opened. Eating allowed in-house for 50% seating at a time. Restaurants are allowed to open with minimal crowding.
Theatres, bars, etc. with closed air-conditioning will remain closed. Banks should operate mostly online or mobile services.Client services should be started with 2 sessions: 7.00 am – 12.00 N 12.30 N – 5.30 pm .Services offered once per week per customer.
Different work hours may be introduced to reduce overcrowding in public transport.Daily wage dependent employees are allowed with specific restrictions posed to employers on social distancing and basic hygienic measures. Lottery sellers & other street vendors –allowed with social distancing and basic hygienic measures.
Industries / larger factories to resume work with 2 or more sessions 50% or less employees per roster.Different work hours may be introduced to reduce overcrowding in public transport. Other Religious congregations, large events, political meetings or conferences or cultural gatherings shall continue to be prohibited.
In a broader perspective, Western Province is the economic hub of the country. With a high number of cases reported, WP is still considered as a high risk area. Even with the proposed strategy above for the Colombo Municipality area, it will take longer time to bring back the normalcy and the economic repercussions would be many. As such, a micro planned strategy with inputs from all the relevant non health stakeholders is indispensable.