Making crowd gatherings safe: how and when can we lift restrictions?

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Open article published on MedShr: 13th January 2021
Last updated: 13th January 2021

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How long do we need to socially distance?

While the pandemic has resulted in the development and implementation of numerous behavioural guidelines intended to mitigate transmission, evidence suggests that many of these guidelines are not being followed by enough people to make them optimally effective. Prediction modelling in some literature has suggested that some form of these social distancing measures may be required well into 2024 to prevent overloading of health care systems.[1]

However, social distancing measures impose significant lifestyle changes for the general population, and any potential benefit must be weighed against the risk of non-compliance and restriction fatigue. Indeed, there are well recognised psychological risks of isolation, and well described benefits to societal connections for the individual.

What determines behaviour and adherence to public health recommendations?

Psychologists cite the need for ‘group membership’, for people to feel a connection to larger groups, such as those based on ethnicity or religion, or a feeling of patriotism, such as fans of a football team or crowds that attend large outdoor events.[2]. This need is not currently met in widespread lockdowns. In the religious sphere, for example, many religious gathering and congregations have been on hold or restricted for several months. The Hajj pilgrimage, in which millions gather annually, was restricted to just 1000 attendees with virtual alternatives. A further discussion of restrictions on religious gatherings can be found in this MedShr Open opinion piece.[3]

Various models of health behaviour change suggest motivation is a key predictor for the adoption and maintenance of preventative health behaviours. Behavioural and social scientists are well positioned to strategize how best to pitch COVID-19 prevention interventions and messaging. These target a shared sense of identity, focus on protecting others or each other, align with moral values, and appeal to social consensus or scientific norms.

What has the experience been so far in lifting restrictions?

In recent weeks and months, most countries have, at least for limited periods, relaxed their social distancing measures compared to the early days of the pandemic. When and how a country should ease such restrictions constitutes a central challenge, as there is a need to balance various health, social, and economic concerns.

However, the World Health Organisation (WHO) has warned that a premature lifting of lockdowns could spark a resurgence of infections and cause even more severe, longer-term damage to the economy than exists as a result of lockdowns.[4] A recent public health policy piece in the Lancet details some of the experiences of approaches taken by nine high-income countries and regions that have started to ease COVID-19 restrictions: five in the Asia Pacific region (Hong Kong [Special Administrative Region], Japan, New Zealand, Singapore, and South Korea) and four in Europe (Germany, Norway, Spain, and the UK)[4], see figures 1 and 2.

Figure 1 | Comparative timeline of lockdown imposition and easing of restrictions in various countries [4]
Figure 2 | Some of the key measures implemented to fascilitate easing of restrictions [4]

Can we return to ‘normal’? If so, how?

There is increasing realisation that removing COVID-19 restrictions is not about returning to pre-pandemic ‘normal’ but about gradually and cautiously transitioning to a new normal, while being vigilant for outbreaks and ready to re-impose social distancing or lockdown measures if needed. In this piece[4], several recommendations are made:

  1. Countries can move forward on the basis of real-time epidemiology and other select considerations, including hospital services. A clear and transparent plan that describes which factors are being taken into account is needed, which should detail the criteria for escalation or relaxation of restrictions.

  2. Countries should not ease restrictions until they have robust systems in place to closely monitor the infection situation. R values cannot be a sole decision-making predictor, as this value requires data of high quality in real time.

  3. Continued measures to reduce transmission will be needed for some time. For example, decreasing interactions to a few repeated contacts to create social bubbles, as pioneered by New Zealand, can allow interaction while reducing transmission.

  4. Governments should educate, engage, and empower all members of society, including the most vulnerable, to participate in the pandemic response, with their direct involvement.

Each country should have an effective find, test, trace, isolate, and support system in place. Identifying and isolating mild and asymptomatic cases can significantly reduce R values, health-care burden, and overall fatality.

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[1] Coroiu A, Moran C, Campbell T, Geller AC. Barriers and facilitators of adherence to social distancing recommendations during COVID-19 among a large international sample of adults. PLoS One. 2020;15(10):e0239795. Published 2020 Oct 7. doi:10.1371/journal.pone.0239795

[2] Baraniuk C. Covid-19: People are gathering again, but can crowds be made safe?. BMJ. 2020;371:m3511. Published 2020 Oct 2. doi:10.1136/bmj.m3511

[3] MedShr Open Guest Editorial: Muslim faith and COVID-19: Do faith communities limit or increase the spread of the new Coronavirus? Available at:

[4] Han E, Tan MMJ, Turk E, et al. Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe. Lancet. 2020;396(10261):1525-1534. doi:10.1016/S0140-6736(20)32007-9

Article by Dr Adam Ali, MedShr Open Editorial Team, Medical Education Fellow

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