The editorial in the Lancet regarding India’s fight against covid is biased and misguided – a detailed rebuttal.

Prof Pankaj Chaturvedi. Tata Memorial Centre

I read the editorial in The Lancet titled India’s Covid -19 emergency published on May 8, 2021. Let me quote from the article “India will see a staggering 1 million deaths from COVID-19 by Aug 1. If that outcome were to happen, Modi’s Government would be responsible for presiding over a self-inflicted national catastrophe.”  It is reminiscent of news reports in the British colonial era in India. To justify their forceful occupation of India, there was an orchestrated attempt of the western media and their political leaders to portray India as the country of fakirs and snake charmers that didn’t deserve to be independent.  When the India’s Independence Bill was being debated in 1947 in the British Parliament, Winston Churchill had unabashedly said, “Power will go into the hands of rascals, rogues, and freebooters.” I felt indignant with a similar vitriolic rant in the editorial leading to poor portrayal of my country. Being in the frontline for last one year in Mumbai, I have witnessed death, disability, disaster and despair. I have lost several of my own near and dear ones. Having said that, criticism is an essential part of any progressive community. I wouldn’t have bothered to write this rebuttal if the editorial was without malice or contempt. As Mahatma Gandhi had said ” Silence becomes cowardice when occasion demands speaking out the whole truth and acting accordingly.”

While the crisis is indeed alarming and saddening, the editorial is suitable for a politically motivated tabloid rather than a reputed academic journal. When things were going wrong in US and UK, we were praying for them rather than writing stinging editorials that too in academic journals. It is time for an end game and not the blame game.

In order to create a sensation, the editorial mentions statistics of mortality and morbidity to suit the purpose. Mark Twain has once described three grades of lies – “Lies, damned lies, and statistics”! Let me present the Indian statistics in a different manner. USA with a population of 0.3 billion population has lost 0.6 million citizens, Brazil with its 0.2 billion population has lost 1.5 million lives, UK with its population of 0.06 billion lost 127000 citizens and France with a population of 0.06 billion lost 106493 of its citizens. India with its 1.3 billion population has lost 262000 Indians and I accept that it is likely to rise further. One may argue about under reporting in India due to low Covid testing in many parts of India. Therefore, let’s look at the case fatality ratio – the number of deaths divided by the number of confirmed cases. India’s CFR of 1.1 % is less than that of the US, France, Italy and Germany! India’s Covid-19 recovery rate is amongst the highest in the world. However, this cannot be a reason for any complacency.

USA started vaccination on 14th December 2020 and vaccinated 256 million to date. UK started on 21st December and vaccinated 53 million till now. Australia started on 22nd Feb and vaccinated 2 million till today. India started on 16th Jan 2021 and has vaccinated 180 million citizens (atleast one dose) as of today that is nearly 9% of its entire population! There are more reasons to appreciate the Indian Government. It lifted the ban on export of HCQ and exported HCQ and Paracetamol during the height of epidemic. Despite shortage of vaccine in India, our government had the magnanimity to export 66 million dosage abroad on humanitarian grounds.

The editorial makes several contradictory remarks and one of them says that the “Local governments have begun taking disease-containment measures, but the federal government has an essential role in explaining to the public covid appropriate behavior.” The fact is that Government has launched a massive multi-pronged Covid awareness campaign and developed a dedicated portal to share all the statistics – . I am also surprised that author is unaware of the several viral genome sequencing data published by the Indian labs. Needless to say, this virus keeps mutating very frequently just like any other influenza virus. Contrary to the claims in the editorial, the central and state governments regularly conduct press conferences to share the emerging data or newer information.

In India’s federal structure, as per the Constitution, health care is a state subject. It is likely that dramatic reduction in the Covid case load during the winter led to a false belief that the pandemic was getting over. Therefore many states were not prepared for the second wave that turned out to be a Tsunami. Even if they had planned, it would be impossible to create an efficient system in less than 6 months. States like Kerala, Maharashtra, Karnataka and Delhi that have better health care systems suffered the most. If we take example of the worldwide mortality, the countries with the best health care infrastructure (US, France, Italy etc) seemed to have the highest mortality. In short, biology trumped technology and pharmacology! With virtually no effective medical treatment currently available, state and central governments have resorted to lockdown multiple times in this entire pandemic. The arm chair critics may not realize that lockdowns are politically challenging decisions. Let us not forget that these measures have profound socio-economic impact that may turn out to be more hazardous than Covid itself especially among the impoverished groups. I am appalled by the Editor’s statement that “government’s attempt to stifle criticism and open discussion during the crisis are inexcusable.” I am confident that the editor has never watched the Indian television debates where such criticisms happen ad nauseum. In fact, the vehement criticism of the Indian vaccines by some political parties made some gullible citizens believe that the vaccines were useless leading to lukewarm response in the beginning.

Now let’s discuss about the failure of the Indian Election commission in deferring the elections. The editor blamed Indian government for failing to heed the warning of the second wave of the pandemic! If that is the case, predictions are being made of a much larger third wave in India! Will the editor please let us know when India could have conducted the elections safely? Is the author aware of the consequences of indefinite postponement of elections in politically sensitive states of West Bengal, Tamil Nadu and Kerala? Having said that, large gatherings were completely unacceptable.

Kumbha Mela is one of the largest voluntary religious congregations of human beings on earth that happens every 12 year in the months of January to April. It was not a wise things to permit it during the pandemic. However, Let me share a thought provoking perspective on this issue. The entire Kumbha area was spread over 150 square kilometer and over 9 million people voluntarily visited it between January till April 2021. The maximum number of people visiting the Kumbha area on a single day was 3.5 million in an area of 15 square kilometres. On that day of peak foot fall, the population density at Kumbha area is estimated as nearly 200000 people per square kilometer. With nearly 17 and 13 million population respectively, Delhi and Mumbai are the India’s two largest cities. The population density of Mumbai is approximately 30,000 per square kilometer of that nearly 40 per cent live in the slums. That means Mumbai and many metropolitan cities lives with Kumbh like situation every day. Dharavi, a locality in Mumbai, is Asia’s largest slum that has population density of nearly 277136 per square kilometer. Compare it to London that has population density of 6000 per square kilometer. Mumbai’s local trains, the life line of the city, carry 7.5 million people (population of Hongkong) every day with nearly 6000 passengers packed into a 12 or 15 car rake during the peak hour. When the lockdowns were lifted during the pandemic (February and March, 2021), nearly 4 million passengers travelled every day in the Mumbai local trains. While the developed world may look down upon these as uncivilized conditions, it probably gave this population a distinct advantage. In August 2020, a seroprevalence study reported presence of antibody among 54 percent of the slum population and 16 percent of the non-slum population. The study concluded that asymptomatic spread of covid led to significantly lower fatality rate among slums compared to non-slums. The reasons why slum dwellers fared better than the rich was because of the high population density, poor hygiene and non-adherence to Covid appropriate behavior! Similar high prevalence of protective antibodies were reported in the other parts of India as well – Delhi (56%)Mumbai (up to 75%) and Hyderabad (54%) and Bengaluru (57.9%). In contrast, the highest level of antibody achieved in New YorkLondon and Paris was 20%, 13% and 12% respectively. Is Indian’s high level of herd immunity responsible for the low case fatality rate? Herd immunity (also called population immunity) is due to the presence of antibodies that occurs when a population acquires it through either the infection (asymptomatic or symptomatic) or vaccination. As I said, this is only a hypothesis generating thought and by no means a logic to defend Kumbha or such large gatherings. Allowing infection to ravage the population is not the best way to achieve Herd immunity. With vaccine as the only hope to combat the spread, it is time to make it more affordable and accessible. Ironically, while thousands are dying every day, Word Trade Organization has failed to prevail upon member countries to waive patents and intellectual property rights linked to vaccines and technologies. The waiver is being fiercely opposed by many developed countries such as UK and European Union. Even an international association of Pharmaceutical Manufacturers warned WTO that waiving the patents and copyrights will be counterproductive and dangerous.  

With hopelessness all around, society tends to hold the political leadership as the ultimate cause of their miseries. I agree that political leaders are accountable and they cannot shift the blame for this failure. However, there are many stakeholders in this pandemic whose accountability needs to be questioned. How about those researchers whose misleading recommendations were later proven to be ineffective or even harmful? What about those journals who shortened the publication pipeline to improve citation index only to end up with substandard articles? We can’t forget the retraction of an article from a reputed journal claiming effectiveness of HCQ. We still remember the allegations of pharma industry – journal nexus in publishing pharma funded studies of questionable benefits. What about those Television channels whose round the clock broadcast of horrifying news mainly for TRP has aggravated the mental agony of the gullible viewers and exhausted frontline workers ? What about the pharma companies who failed to communicate about lack of efficacy or appropriate usage while selling lopinavir, ritonavir, oseltamivir, remdesivir, interferons, tocilizumab, hydroxychloroquine, azithromycin etc? Will the scientists, institutions and the rich nations apologize to the world for holding on to the patents/copyrights of the lifesaving drugs and equipment while thousands die every day?

The Lancet editorial made a ludicrous statement that “Government has seemed more intent on removing criticism on Twitter than trying to control the pandemic”. It is well known that the states and the center have been tirelessly working against this Tsunami that has inundated our already constrained infrastructure. We need to be better prepared for the possible third wave.

The Lancet editorial seemed to be solely for the media attention and trending on twitter while maligning India globally. In the word of German Scholar, Max Mueller, “If I were asked under what sky the human mind has most fully developed some of its choicest gifts, has most deeply pondered on the greatest problems of life, and has found solutions, I should point to India.” Wait till India recovers, it will lead the world soon.