COVID-19 – Close Read

Homo medicatis

With Covishield in my body, I feel like there is a capillary tube erupting from the Ministry of Health and Family Welfare, and its panoply of attendant bodies vis-à-vis India’s COVID-19 response, soaring across the length of India and plunging into my veins, somewhere in Bangalore. And with every tug away from the compulsions of public healthcare and towards petty politics, the needle tugs at me in turn, its point dragging through my flesh, the blunt cylinder of its form cutting through my skin. I feel a bloodless injury on my body inflicted by an apathetic actor hundreds of leagues distant, and utterly powerless for it. Can you imagine the assault of such a foe? There’s the simple brutality of its strength and then there’s the ignominy of being told that your wounds are accidental, that you deserved neither the attention of your alleged assailant nor the consideration that everyone else has reserved for designated survivors. There is even pain but I cannot hear its wail clearly; it seems to originate from somewhere deep within me, so deep I can only hear its fading screams for help. I am doused in a sourceless, timeless numbness – the site of a revolution that is both ongoing and dead. I am the foregone conclusion of the state’s subjection, the fixed destination – one of many millions, of course – of whatever vaccines, drugs, therapies and philosophies it is determined to wreak; I am simultaneously the constant source of its strength. Imagine a god sustained by the faith of the dying-but-never-dead; does it take not their submission or prayers but their persistence in the face of diseases it will unleash for granted? When it increased the dose gap for Covishield from four to fix, then eight, then twelve and finally to sixteen weeks, the needle tore and tore and tore. Every change was a humiliating reminder of the control the state has grown to exert on me, on the fundamental biochemical defences millennia of evolution has instilled in my body, your body, our bodies. It is unacceptable at this point to insist that one dose of Covishield later, we are X% protected against mild disease and Y% against disease-requiring-hospitalisation by the delta variant. The variant has little to do with why I am reluctant to catch a flight to Delhi, where I long to be, or why the first thought when I wake in the morning is to wonder which member of my extended family has become the latest to succumb this year. Why, even before the vaccine, I was rendered mad ahead of choosing between Covaxin and Covishield. There was, and still is, no data in support of one and the other was, and still is, triggering terrifying – yet rare – blood-related consequences in some people, and both sat poorly with my knowledge of my own illnesses. And this was just me, a person aware of and able to navigate this swamp of nefarious possibilities; what of those who knew less, or knew but could do little to ensure the best outcomes for themselves? Would they be the triply ignominious, the triply neglected? Such foul and abject degradation. I have friends and family who expect to hear from me answers to their questions about how the vaccines work, what the new variants of concern are, and what they themselves ought and ought not to do. But even as I prepare, I become keenly aware of being conscripted to the state’s myth-machine – with the first utterance of “don’t worry” to fall in line with the other GI Joes. But only one misstep and the state waits, on the other side of the road, with irons at the ready to accuse us of lying, or of course seceding. And so the path ahead, the path of a free and unfettered citizen, becomes narrower and narrower, until we are all just needles in veins.

What is more, his entire existence is reduced to a bare life stripped of every right by virtue of the fact that anyone can kill him without committing homicide; he can save himself only in perpetual flight or a foreign land.
Homo Sacer: Sovereign Power and Bare Life (1995), Giorgio Agamben

COVID-19, AMR and India

Maybe it’s not a coincidence that India is today the site of the world’s largest COVID-19 outbreak and the world’s most prominent source of antimicrobial resistant (AMR) pathogens, a.k.a. ‘superbugs’. The former fiasco is the product of failures on multiple fronts – including policy, infrastructure, logistics, politics and even ideology, before we need to consider faster-spreading variants of the novel coronavirus. I’m not sure of all the factors that have contributed to AMR’s burgeoning in India; some of them are irrational use of broad-spectrum antibiotics, poor public hygiene, laws that disprivilege ecological health and subpar regulation of hospital practices.

But all this said, both the second COVID-19 wave and the rise of AMR have benefited from being able to linger in the national population for longer. The longer the novel coronavirus keeps circulating in the population, the more opportunities there are for new variants to appear; the longer pathogens are exposed repeatedly to antimicrobial agents in different environments, the more opportunities they have to develop resistance. And once these things happen, their effects on their respective crises are exacerbated by the less-than-ideal social, political and economic contexts in which they manifest.

Again, I should emphasise that if these afflictions have been assailing India for such a long time and in increasingly stronger ways, it’s because of many distinct, and some overlapping, forces – but I think it’s also true that the resulting permission for pathogens to persist, at scale to boot, makes India more vulnerable than other countries might be to problems of the emergent variety. And given the failures that give rise to this vulnerability, this can be one hell of a vicious cycle.

Good luck with your Maggi

You know when you’re cooking a packet of Maggi noodles in a saucepan, and you haven’t used enough water or don’t move the stuff soon enough from the pan to a plate once it’s done cooking, and you’re basically left with a hot lump of maida stuck to the bottom? That’s 2020. When you cook Maggi right, right up to mixing in a stick of butter at the end, you get a flavourful, well-lubricated, springy mass of strings that’s a pleasure to eat at the end of a long day. Once in a while you stick a fork into the plate and pull up a particularly long noodle, and you relish sucking it into your mouth from start to finish, with the masala dripping off at the end. That was probably many other years – when you had a strong sense of time moving from one event to the next, a sense of progression that helps you recall chronologies even long after you’ve forgotten what happened in March and what in September. For example, 2015 in my mind is cleanly divided into two parts – before May 11 and after May 11 – and memories of little personal accomplishments from that time are backgrounded by whether The Wire existed at the time. If it did, then I know the accomplishment happened after May 11. The Wire‘s birth effectively became an inflection in time that cut a little notch in the great noodle of 2015, a reference mark that created a before and an after. 2020 had none of this. It forsook all arrows of time; it wasn’t linear in any sense, not even non-linear in the sense of being exponential or logarithmic. It was practically anti-linear. Causality became a joke as the pandemic and its attendant restrictions on society fucked with the mind’s ability to tell one day apart from the next. So many of us beheld the world from our windows or balconies, although it wasn’t as if the world itself moved on without us. We weren’t there to world the world. Or maybe we were, but our collective grief at being imprisoned, literally and otherwise, seemed to be able to reshape our neighbourhoods, our surroundings, our shared cosmologies even and infused the fabrics of our every day with a cynical dye that we know won’t come off easily. Many of our lived experiences carried an awful symmetry like the circular one of a bangle, or a CD. How do you orient it? How do you say which way is up, or left, just by looking at it? You can’t. In the parlance of Euclidean geometry, 2020 was just as non-orientable. There was no before and after. Even our universe isn’t as bad: despite the maddening nature of the flatness problem, and the even more maddening fact of Earth’s asymptotically infinite loneliness, the universe is nearly flat. You’d have to travel trillions upon trillions of light-years in any direction before you have any chance of venturing into your past, and even then only because our instruments and our sciences aren’t accurate enough to assert, with complete certainty, that the universe is entirely flat and that your past will always lie in the causal history of your future. 2020 was, however, a singularity – an entrapment of reality within a glass bubble in which time flowed in an orbit around the centre, in perpetual free-fall and at the same time managing to get nowhere really. You can forget teasing out individual noodles from the hot lump on your plate because it’s really a black hole, probably something worse for shunning any of the mysteries that surround the microscopic structure of black holes in favour of maida, that great agent of constipation. As you stare at it, you could wait for its effects to evaporate; you could throw more crap into it in the hopes of destabilising it, like pushing yourself to the brink of nihilism that Thucydides noticed among the epidemic-stricken people of Athens more than two millennia ago; or you could figure out ingenious ways à la Penrose to get something good out of it. If you figure this out, please let the rest of us know. And until then, good luck with your Maggi.

Super-spreading, mobility and crowding

I still see quite a few journalists in India refer to “super-spreaders” vis-à-vis the novel coronavirus – implying that some individuals might be to blame for ‘seeding’ lots of new infections in the community – instead of accommodating the fact that simply breathing out a lot of viruses doesn’t suffice to infect tens or hundreds of others: you also need the social conditions that will enable all these viral particles to easily find human hosts.

In fact, going a step ahead, a super-spreading event can happen if there are no super-spreading individuals but there are enabling environmental conditions that do nothing to slow the virus’s transmission across different communities. These conditions include lack of basic amenities (or access to them) such as clean water, nutritious meals and physical space.

A new study published by a group of researchers from the US adds to this view. According to their paper’s abstract, “Our model predicts higher infection rates among disadvantaged racial and socioeconomic groups solely from differences in mobility: we find that disadvantaged groups have not been able to reduce mobility as sharply, and that the POIs [points of interest] they visit are more crowded and therefore higher-risk.”

And what they suggest by way of amelioration – to reduce the maximum occupancy at each POI, like a restaurant – applies to a mobility-centric strategy the same way reducing inequality applies to a strategy centred on social justice. In effect, disadvantaged groups of people – which currently include people forced to live in slums, share toilets, ration water, etc. in India’s cities – should have access to the same quality of life that everyone else does at that point of time, including in the limited case of housing.

This study is also interesting because the authors’ model was composed with mobility data from 98 million cellphones – providing an empirical foundation that obviates the need for assumptions about how people move and where. In the early days of India’s COVID-19 epidemic, faulty assumptions on just this count gave rise to predictions about how the situation would evolve in different areas that in hindsight were found to be outlandish – and in some cases in ways that could have been anticipated.

Some modellers denoted people as dots on a screen and assumed that each dot would be able to move a certain distance before it ‘met’ another dot, as well as that all the dots would have a certain total area in which to move around. But as two mathematicians wrote for Politically Math in April this year, our cities look nothing like this:

According to this report, “India’s top 1% bag 73% of the country’s wealth”. Let us say, the physical space in our simulation represents not the ‘physical space’ in real terms, but the ‘space of opportunities’ that exist. In this specific situation of a country under complete lockdown because of the pandemic, this might mean who gets to order ‘contactless’ food online while being ‘quarantined’ at home, and who doesn’t. In our segregated simulation space therefore, the top chamber must occupy 73% of the total space, and the bottom chamber 27%. Also, 1% of the total number of dots occupy the airy top chamber, while the remaining 99% of the dots occupy the bottom chamber.

As a result, and notwithstanding any caveats about the data-taking exercises, researchers reported that Dharavi in Mumbai had a seroprevalence of more than 50% by late July while three wards in non-slum areas had a seroprevalence of only 16%.

The flawed models still can’t claim they could have been right if Mumbai’s slum and non-slum areas were treated as distinct entities. As T. Jacob John wrote for The Wire Science in October, one of the reasons (non-vaccine) herd immunity as a concept breaks when applied to humans is that humans are social animals, and their populations regularly mix such that ‘closed societies’ are rendered practically impossible.

So instead of mucking about with nationwide lockdowns and other restrictions that apply to entire populations at once, the state could simply do two things. First, in the short-term, prevent crowding in places where it’s likely to happen – including public toilets that residents of slums are forced to share, ration shops where beneficiaries of the PDS system are required to queue up, workplaces where workers are crammed too many to a room, etc.

Obviously, I don’t suggest that the government should have been aware of all these features of the epidemic’s progression in different areas from the beginning. But from the moment these issues became clear, and from the moment a government became able to reorient its COVID-19 response strategy but didn’t, it has effectively been in the dock.

This brings us to the second and longer term thing we should do: with the novel coronavirus’s transmission characteristics as a guide, we must refashion policies and strategies to reduce inequality and improve access to those resources required to suppress ‘super-spreading’ conditions at the same time.

The simultaneity is important. For example, simply increasing the average house size from 4 sq. m, say, to 8 sq. m won’t cut it. Instead, buildings have to be designed to allow ample ventilation (with fresh air) and access to sunlight (depending on its natural availability). As researchers from IDFC Institute, a think-tank in Mumbai, noted in another article:

Dharavi’s buildings and paths are irregularly laid out, with few straight routes. Based on calculations with OpenStreetMap routes and Google Earth imagery, it appears 68% of pathways and roads are less than 2 m wide. Such a dimension offers little space for air circulation, and reduces airflow relative to other, properly planned areas, and admits fewer air currents that could help break up the concentration of viral particles.

Mitigating such conditions could also impinge on India’s climate commitments. For example, with reference to our present time in history as the hottest on record, and many countries including India experiencing periods in which the ambient temperature in some regions exceeds thresholds deemed safe for human metabolism, science writer Leigh Phillips wrote for Jacobin that air-conditions must be a human right:

What would it mean to have a right to air-conditioning? Precisely, the right should be to have free or cheap, reliable access to the thermal conditions optimal for human metabolism (air temperatures of between 18 degrees C and 24 degrees C, according to the WHO). Neither too hot nor too cold. The right to Goldilocks’s porridge, if you will. New buildings must come with A/C as part of any “Green New Deal”. The aim of any programme of publicly subsidised mass retrofitting of old buildings shouldn’t be just to fuel-switch away from gas heating and improve insulation, but also to install quiet, efficient air-conditioning systems. At the scale of the electricity grid, this demand must also include the requirement that A/C run on cheap, clean electricity.

So really, none of what’s going on is simple – and when governments respond by offering solutions that assume the problem is simple are avoiding dealing with the real causes. For example, ‘super-spreading’ is neither a choice nor an event – it’s a condition – so solutions that address it as a choice or event are bound to fail. Seen the other way, a community with a high prevalence of a viral infection may be much less responsible for its predicament than the simple interaction of their social conditions with a highly contagious virus.

But this doesn’t mean no solution except a grand, city-scale one can be feasible either – only that all solutions must converge, by being targeted to that effect, on eliminating inequalities.

Trump, science denial and violence

For a few days last week, before the mail-in votes had been counted in the US, the contest between Joe Biden and Donald Trump seemed set for a nail-biting finish. In this time a lot of people expressed disappointment on Twitter that nearly half of all Americans who had voted (Trump’s share of the popular vote was 48% on November 5) had done so for anti-science and science denialism.

Quite a few commentators also went on to say that “denying science is not just another political view”, implying that Trump, who has repeatedly endorsed such denialism, isn’t being a part of the political right as much as stupid and irresponsible.

This is a reasonable deduction but I think it’s also a bit more complicated. To my mind, a belief that “denying science is not just another political view” could be unfair if it keeps us from addressing the violence perpetrated by some supporters of science, and the state in the name of science.

Almost nowhere does science live in a vacuum, churning out silver bullets to society’s various ills; and in the course of its relationship with the state, it is sometimes a source of distress as well. For example, when the scientific establishment adopts non-democratic tactics to set up R&D facilities, like in Challakere, Kudankulam and Theni (INO); when unscrupulous hospitals fleece patients by exploiting their medical illiteracy; and when ineffective communication and engagement in ‘peace time’ leads to impressions during ‘wartime’ that science serves only a particular group of people, or that ‘science knows best’. These are just a few examples.

Of course, belief in pseudo-Ayurvedic treatments and astrological predictions arise due to a complicated interplay of factors, including an uncritical engagement with the status quo and the tendency to sustain caste hierarchies. We must also ask who is being empowered and why, since Ayurveda and astrology also perpetrate violences of their own.

But in this mess, it’s important to remember that science can be political as well and that choosing science can be a political act, and that by extension opposing or denying science can be a political view as well – particularly if there is also an impression that science is something that the state uses to legitimise itself (as with poorly crafted disease transmission models), often by trampling over the rights of the weak.

This is ultimately important because erasing the political context in which science denialism persists could also blind us to the violence being perpetrated by the support for science and scientism, and its political context.

When I sent a draft of the post so far to a friend for feedback, he replied that “the sympathetic view of science denialism” that I take leads to a situation where “one both can and can’t reject science denialism as a viable political position.” That’s correct.

“Well, which one is it?”

Honestly, I don’t know, but I’m not in search of an answer either. I simply think non-scientific ideas and organisations are accused of perpetrating violence more often than scientific ones are, so it’s important to interrogate the latter as well lest we continue to believe that simply and uncritically rooting for science is sufficient and good.

Thermal gun, sanitiser and volatility

Most of the shops I visit to purchase my supplies dispense an alcohol-based hand-sanitiser at the point of entry and have a person stationed there to check customers’ body temperature with a contactless thermal gun. They used to point the gun at the forehead but of late many of them have started aiming it at the other side of the palm, to be held outstretched. I don’t know if this is okay or not – but I doubt it’s okay to point the thermal gun at the hand just after you’ve doused it in sanitiser.

Alcohol’s two properties of interest in this context are that it’s a disinfectant and that it’s volatile. After you’ve applied it, your hand feels cooler because each droplet of the alcohol absorbs a tiny bit of heat from your body and evaporates. This is also why you and others around you can smell the sanitiser’s fragrance spreading: the alcohol molecules are airborne and floating about, no longer localised to a smaller area.

The difference between a liquid and a gas is that molecules in the liquid are held together by bonds between hydrogen atoms and certain electron-rich atoms – for example, oxygen in the case of water. These bonds can be broken by heat. Volatile liquids have fewer of these bonds, so they need less heat to transition from the liquid to the gaseous phases. These liquids have relatively lower boiling points (than water in the same conditions) for the same reason – 78.3º C and 82.5º C for ethyl alcohol and isopropyl alcohol respectively.

If at this point the thermal gun is pointed at the hand, I’m not sure it would still be able to pick up a fever – especially a milder one close to the threshold of 99º F. The cooling effect is transient but the sanitisation and the temperature check happen within seconds of each other. I’m also not sure how effective thermal guns have been in general at screening people with fever at various checkpoints. But if they are, pointing them at the forehead or at the hand but before using the sanitiser could easily preclude one issue.

Pandemic: A world-building exercise

First, there was ~~light~~ news of a vaccine against COVID-19 nearing the end of its phase 3 clinical trials with very promising results, accompanied with breezy speculations (often tied to the stock prices of a certain drug-maker) about how it’s going to end the pandemic in six months.

An Indian disease-transmission modeller – of the sort who often purport to be value-free ‘quants’ interested in solving mathematical puzzles that don’t impinge on the real world – reads about the vaccine and begins to tweak his models accordingly. Soon, he has a projection that shines bright in the dense gloom of bad news.

One day, as the world is surely hurtling towards a functional vaccine, it becomes known that some of the world’s richest countries – representing an eighth of the planet’s human population – have secreted more than half of the world’s supply of the vaccine.

Then, a poll finds that over half of all Americans wouldn’t trust a COVID-19 vaccine when it becomes available. The poll hasn’t been conducted in other countries.

A glut of companies around the world have invested heavily in various COVID-19 vaccine candidates, even as the latter are yet to complete phase 3 clinical trials. Should a candidate not clear its trial, a corresponding company could lose its investment without insurance or some form of underwriting by the corresponding government.

Taken together, these scenarios portend a significant delay between a vaccine successfully completing its clinical trials and becoming available to the population, and another delay between general availability and adoption.

The press glosses over these offsets, developing among its readers a distorted impression of the pandemic’s progression – an awkward blend of two images, really: one in which the richer countries are rapidly approaching herd immunity while, in the other, there is a shortage of vaccines.

Sooner or later, a right-wing commentator notices there is a commensurately increasing risk of these poorer countries ‘re-exporting’ the virus around the world. Politicians hear him and further stigmatise these countries, and build support for xenophobic and/or supremacist policies.

Meanwhile, the modeller notices the delays as well. When he revises his model, he finds that as governments relax lockdowns and reopen airports for international travel, differences in screening procedures in different countries could allow the case load to rise and fall around the world in waves – in effect ensuring the pandemic will take longer to end.

His new paper isn’t taken very seriously. It’s near the end of the pandemic, everyone has been told, and he’s being a buzzkill. (It’s also a preprint, and that, a senior scientist in government nearing his retirement remarks, “is all you need to know”.) Distrust of his results morphs slowly into a distrust towards scientists’ predictions, and becomes ground to dismiss most discomfiting findings.

The vaccine is finally available in middle- and low-income countries. But in India, this bigger picture plays out at smaller scales, like a fractal. Neither the modeller nor the head of state included the social realities of Indian society in their plans – but no one noticed because both had conducted science by press release.

As they scratch their heads, they also swat away at people at the outer limits of the country’s caste and class groups clutching at them in desperation. A migrant worker walks past unnoticed. One of them wonders if he needs to privatise healthcare more. The other is examining his paper for arithmetic mistakes.

Spray and pray – the COVID-19 version

Kiran Mazumdar-Shaw is the head of Biocon, a company headquartered in Bengaluru and which has repurposed a drug called itolizumab – already approved to help manage severe chronic psoriasis in different markets – to manage cytokine release syndrome (CRS) in COVID-19 patients. Setting aside CRS’s relevance in the COVID-19 pathology (considering it is currently in dispute), Mazumdar-Shaw and a specific coterie of Biocon employees have been aggressively marketing itolizumab despite the fact that its phase II clinical trial seems by all accounts to have been a joke. (I recommend this account.)

Funnily enough, The Print published an article by Mazumdar-Shaw on September 1, in which she describes her experience of the infection (she’s one of The Print‘s funders). Two portions of the article are striking. One is the following paragraph about her treatment, which tacitly implicates a host of drugs and devices in her recovery without providing any additional information of their respective usefulness:

Dr Murli Mohan from Narayana Health, Bengaluru and Dr Shashank Joshi from Lilavati hospital, Mumbai, were my key medical supervisors. I was put on a course of Favipiravir, azithromycin and paracetamol. Apart from this, I continued with my daily dose of Vitamin C, Vitamin D, Zinc, baby aspirin and chyavanprash. Not to mention my twice a week 200mg dose of HCQ. Day two and three were uneventful. I was measuring my oxygen saturation levels six times a day, which were all between 96-98 per cent even after a brisk six-minute walk. My temperature was normal but late evening on Day three, I felt fluish and it extended to Day four and five. No measurable temperature but frequent bouts of sweating, which suggested that my body was fighting the virus. I was also tracking my Cytokine levels.

Reading this brought to mind a terrible period in early 2010, when I had malaria and jaundice together with an unusually strong spate of migraines. I can’t remember the exact drugs and diet that got me feeling better. But after reading what Mazumdar-Shaw went through, I’m inclined to attribute my recovery also to the mug of Bournvita I had every night before bed.

The other striking portion is a list of suggestions that subtly make the case to pay more attention to CRS and treat it with the drugs available in the market for it: “Doctors should not just treat clinical symptoms but rather the cause of the symptoms. If SpO2 (oxygen saturation) reduces, just increasing oxygen flow is not the answer. Treating inflammation caused by cytokines is the answer.” Wonder why researchers don’t yet have consensus… But the Drug Controller General of India has approved two drugs to treat CRS due to COVID-19 in India (through a highly criticised approval process) – and Kiran Mazudar-Shaw’s Biocon’s itolizumab is one of them.

The list is also prefaced by the following statement, among others: “… avoid TV and social media as negative news is bad for fighting Covid-19.” I wonder if this refers to criticism against hydroxychloroquine (HCQ), favipiravir, azithromycin and purported Ayurvedic remedies as well.

India’s missing research papers

If you’re looking for a quantification (although you shouldn’t) of the extent to which science is being conducted by press releases in India at the moment, consider the following list of studies. The papers for none of them have been published – as preprints or ‘post-prints’ – even as the people behind them, including many government officials and corporate honchos, have issued press releases about the respective findings, which some sections of the media have publicised without question and which have quite likely gone on to inform government decisions about suitable control and mitigation strategies. The collective danger of this failure is only amplified by a deafening silence from many quarters, especially from the wider community of doctors and medical researchers – almost as if it’s normal to conduct studies and publish press releases in a hurry and take an inordinate amount of time upload a preprint manuscript or conduct peer review, instead of the other way around. By the way, did you know India has three science academies?

ICMR’s first seroprevalence survey (99% sure it isn’t out yet, but if I’m wrong, please let me know and link me to the paper?)
Mumbai’s TIFR-NITI seroprevalence survey (100% sure. I asked TIFR when they plan to upload the paper, they said: “We are bound by BMC rules with respect to sharing data and hence we cannot give the raw data to anyone at least [until] we publish the paper. We will upload the preprint version soon.”)
Biocon’s phase II Itolizumab trial (100% sure. More about irregularities here.)
Delhi’s first seroprevalence survey (95% sure. Vinod Paul of NITI Aayog discussed the results but no paper has pinged my radar.)
Delhi’s second seroprevalence survey (100% sure. Indian Express reported on August 8 that it has just wrapped up and the results will be available in 10 days. It didn’t mention a paper, however.)
Bharat Biotech’s COVAXIN preclinical trials (90% sure)
Papers of well-designed, well-powered studies establishing that HCQ, remdesivir, favipiravir and tocilizumab are efficacious against COVID-19 🙂

Aside from this, there have been many disease-transmission models whose results have been played up without discussing the specifics as well as numerous claims about transmission dynamics that have been largely inseparable from the steady stream of pseudoscience, obfuscation and carelessness. In one particularly egregious case, the Indian Council of Medical Research announced in a press release in May that Ahmedabad-based Zydus Cadila had manufactured an ELISA test kit for COVID-19 for ICMR’s use that was 100% specific and 98% sensitive. However, the paper describing the kit’s validation, published later, said it was 97.9% specific and 92.37% sensitive. If you know what these numbers mean, you’ll also know what a big difference this is, between the press release and the paper. After an investigation by Priyanka Pulla followed by multiple questions to different government officials, ICMR admitted it had made a booboo in the press release. I think this is a fair representation of how much the methods of science – which bridge first principles with the results – matter in India during the pandemic.

The matter of a journal’s reputation

Apparently (and surprisingly) The Telegraph didn’t allow Dinesh Thakur to respond to an article by Biocon employee Sundar Ramanan, in which Ramanan deems Thakur’s article about the claims to efficacy of the Biocon drug Itolizumab not being backed by enough data to have received the DCGI’s approval to be inaccurate. Even notwithstanding The Telegraph‘s policy on how rebuttals are handled (I have no idea what it is), Ramanan – as a proxy for his employer – has everything to gain by defending Itolizumab’s approval and Thakur, nothing. This fact alone means Thakur should have been allowed to respond. As it stands, the issue has been reduced to a he-said-she-said event and I doubt that in reality it is. Thakur has since published his response at Newslaundry.

I’m no expert but there are many signs of whataboutery in Ramanan’s article. As Thakur writes, there’s also the matter of the DCGI waiving phase III clinical trials for Itolizumab, which can only be done if phase II trials were great – and this they’re unlikely to have been because of the ludicrous cohort size of 30 people. Kiran Mazumdar-Shaw and Seema Ahuja, the former the MD of and the latter a PR person affiliated with Biocon, have also resorted to ad hominem arguments on Twitter against Itolizumab’s critics, on more than one occasion have construed complaints about the drug approval process as expressions of anti-India sentiments, and have more recently begun to advance company-sponsored ‘expert opinions’ as “peer-reviewed” evidence of Itolizumab’s efficacy.

Even without presuming to know who’s ultimately right here, Mazumdar-Shaw and Ahuja don’t sound like the good guys, especially since their fiercest critics I’ve spotted thus far on Twitter are a bunch of highly qualified public health experts and medical researchers. Accusing them of ‘besmirching India’ inspires anything but confidence in Itolizumab’s phase II trial results.

It’s in this context that I want to draw attention to one particular word in Ramanan’s article in The Telegraph that I believe signals the ‘you scratch my back, I scratch yours’ relationship between many scientific journals and the accumulation of knowledge as a means to power – and in my view is a further sign that something’s rotten in the state of Denmark. Ramanan writes (underline added):

Itolizumab was first approved by the Drugs Controller General of India for the treatment of patients with active moderate to severe chronic plaque Psoriasis in 2013 based on “double-blind, randomized, placebo-controlled, Phase III study”. The safety and efficacy of the drug was published in globally reputed, peer-reviewed journals and in proceedings (Journal of the American Academy of Dermatology, and the 6th annual European Antibody Congress, respectively).

What does a journal’s reputation have to do with anything? The reason I keep repeating this point is not because you don’t get it – I’m sure you do; I do it to remind myself, and everyone else who may need to be reminded, of the different contexts in which the same issue repeatedly manifests. Invoking reputation, in this instance, smells of an argument grounded in authority instead of in evidence. Then again, this is a tautological statement considering Biocon issued a press release before the published results – preprint or post-print – were available (they still aren’t), but let’s bear on in an attempt to make sense of reputation itself.

The matter of a journal’s reputation, whether local or global, is grating because the journals for whom this attribute is germane have acquired it by publishing certain kinds of papers over others – papers that tend to describe positive results, sensational results, and by virtue of their reader-pays business model, results that are of greater interest to those likely to want to pay to access them. These details are important because it’s important to ask what ‘reputation’ means, and based on that we can then understand some of the choices of people for whom this ‘reputation’ matters.

Reputation is the outcome of gatekeeping, of deeming some papers as being worthy of publication according to metrics that have less to do with the contents of the paper* and more with the journal’s desirability and profitability. As Björn Brembs wrote in 2010:

It doesn’t matter where something is published – what matters is what is being published. Given the obscene subscription rates some of these journals charge, if anything, they should be held to a higher standard and their ‘reputation’ (i.e., their justification for charging these outrageous subscription fees!) being constantly questioned, rather than this unquestioning dogma that anything published there must be relevant, because it was published there.

However, by breaking into an élite club by publishing a paper in a particular journal, the reputation starts to matter to the scientist as well, and becomes synonymous with the scientist’s own aspirations of quality, rigour and academic power (look out for proclamations like “I have published 25 papers in journal X, which has an impact factor of 43″). This way, over time, the scientific literature becomes increasingly skewed in favour of some kinds of papers over others – especially of the positive, sensational variety – and leads to a vicious cycle.

The pressure in academia to ‘publish or perish’ also forces scientists to shoehorn themselves tighter into the journals’ definition of what a ‘good’ paper is, more so if publishing in some journals has seemingly become associated with increasing one’s likelihood of winning ‘reputed’ awards. As such, reputation is neither accidental nor innocent. From the point of view of the science that fills scientific journals, reputation is an arbitrary gatekeeper designed to disqualify an observer from calling the journal’s contents into question – which I’m sure you’ll understand is essentially antiscientific.

Ramanan’s appeal to the reputation of the journal that published the results of the tests of Itolizumab’s efficacy against cytokine release syndrome (CRS) in psoriasis patients is, in similar vein, an appeal to an entity that has nothing to do either with the study itself or the matter at hand. As Dr Jammi Nagaraj Rao wrote for The Wire Science, there’s no reason for us to believe knowing how Itolizumab works against CRS will help us understand how it will work against CRS in COVID-19 patients considering we’re not entirely sure how CRS plays out in COVID-19 patients – or if Itolizumab’s molecular mechanism of action can be directly translated to a statement of efficacy against a new disease.

In effect, the invitation to defer to a journal’s reputation is akin to an invitation to hide behind a cloak of superiority that would render scrutiny irrelevant. But that Ramanan used this word in this particular context is secondary**; the primary issue is that journals that pride such arbitrarily defined attributes as ‘reputation’ and ‘prestige’ also offer them as a defence against demands for transparency and access. Instead, why not let the contents of the paper speak up for themselves? Biocon should publish the paper pertaining to its controversial phase II trial of Itolizumab in COVID-19 patients and the DCGI should publicise the inner workings of its approval process asap. As they say: show us (the results), don’t tell us (the statement).

* Beyond determining if the paper is legitimate, has sound science and is free of mistakes, malpractice or fraud.

** There are also other words Ramanan uses to subtly delegitimise Thakur’s article – calling it an “opinion article” and presuming to “correct” Thakur’s arguments that constitute a “disservice to the public”.