Against the background of the H5N1 pandemic in birds and an epidemic among cattle in the US, the Government of Victoria, in Australia, published a statement on May 21 that the province had recorded the country’s first human H5N1 case. This doesn’t seem to be much cause (but also not negligible cause) for concern because, according to the statement as well as other experts, this strain of avian influenza hasn’t evolved to spread easily between people. The individual in question who had the infection — “a child”, according to Victoria’s statement — had a severe form of it but has since recovered fully as well.
But this story isn’t testament to Australia’s pathogen surveillance, at least not primarily; it’s testament to India’s ability to do it. In Vivek Agnihotri’s film The Vaccine War — purportedly about the efforts of Bharat Biotech, the ICMR, and the NIV to develop Covaxin during the COVID-19 pandemic — Raima Sen, who plays the science editor of a fictitious publication called The Daily Wire, says about developing the vaccine in a moment of amusing cringe on a TV news show that “India can’t do it”. Agnihotri didn’t make it difficult to see myself in Sen’s character: I was science editor of the very real publication The Wire when Covaxin was being developed. And I’m here to tell you that India, in point of fact, can: according to Victoria’s statement, the child became infected by a strain of the H5N1 virus in India and fell ill in March 2024.
And what is it that India can do? According to Victoria’s statement, spotting the infection required “Victoria’s enhanced surveillance system”. Further, “most strains don’t infect humans”; India was able to serve the child with one of the rare strains that could. “Transmission to humans” is also “very rare”, happening largely among people who “have contact with infected birds or animals, or their secretions, while in affected areas of the world”. Specifically: “Avian influenza is spread by close contact with an infected bird (dead or alive), e.g. handling infected birds, touching droppings or bedding, or killing/preparing infected poultry for cooking. You can’t catch avian influenza through eating fully cooked poultry or eggs, even in areas with an outbreak of avian influenza.”
So let’s learn our lesson: If we give India’s widespread dysregulation of poultry and cattle health, underinvestment in pathogen surveillance, and its national government’s unique blend of optimism and wilful ignorance a chance, the country will give someone somewhere a rare strain of an avian influenza virus that can infect humans. Repeat after me: India can do it!
There’s a virus out there among many, many viruses that’s caught the world’s attention. This virus came into existence somewhere else, it doesn’t matter where, and developed a mutation at some point that allowed it to do what it needs to do inside the body of one specific kind of animal: Homo sapiens. And once it enters one Homo sapiens, it takes advantage of its new surroundings to produce more copies of itself. Then, its offspring wait for the animal to cough or sneeze – acts originally designed to expel irritating substances – to exit their current home and hopefully enter a new one. There, these viruses go through the same cycle of reproduction and expulsion, and so forth.
This way, the virus has infected over 210,000 people in the last hundred days or so. Some people’s bodies have been so invaded by the virus that their immune systems weren’t able to fight it off, and they – nearly 9,000 of them – succumbed to it.
Thus far, the virus has reportedly invaded the bodies of at least 282 people in India. There’s no telling how the virus will dissipate through the rest of the population – if it needs to – except by catching people who have the virus early, separating them from the rest of the population for long enough to ensure they don’t have and/or transmit the virus or, if they do, providing additional treatment, and finally reintegrating them with the general population.
But as the virus spreads among more and more people, it’s going to become harder and harder to tell how every single new patient got their particular infection. Ultimately, a situation is going to arise wherein too many people have the virus for public-health officials to be able to say how exactly the virus got to them. The WHO calls this phase ‘community transmission’.
India is a country of over 1.3 billion people, and is currently on the cusp of what the Indian Council of Medical Research (ICMR) has called ‘stage 3’ – the advent of community transmission. It’s impossible to expect a developing country as big and as densely populated as India to begin testing all 1.3 billion Indians for the virus as soon as there is news of the virus having entered the national border because the resource cost required to undertake such an exercise is extremely high, well beyond what India can generally afford. However, this doesn’t mean Indians are screwed.
Instead of testing every Indian, ICMR took a different route. Consider the following example: there’s a population of red flecks randomly interspersed with yellow flecks. You need to choose a small subset of flecks from this grid (shown below) such that checking for the number of yellow flecks in the subset gives you a reliable idea of the number of yellow flecks overall.
The ideal subset would be the whole set, of course, so there is one more catch: you have a fixed amount of money to figure out the correct answer (as well as for a bunch of other activities), so it’s in your best interests to keep the subset as small as possible. In effect, you need to balance the tension between two important demands: getting to a more accurate answer while spending less.
Similarly, ICMR assumed that the virus is randomly distributed in the Indian population, and decided to divide the population into different groups, for example by their relative proximity to a testing centre. That is, each testing centre would correspond to the group of all people who live closer to that testing centre than any other. Then, ICMR would pick a certain number of people from each group, collect their nasal and throat samples and send it to the corresponding labs for tests.
Say group size equals 100. For a Bernoulli random variable with unknown probability p, if no events occur in n independent trials, the maximum value of p (at 95% confidence) is approximately 3/n. In our case, n = 100 and p at 95% confidence is 3/100, which is 3%. Since this is the upper bound, it means less than 3% of the population has the ‘event’ which didn’t occur in n trials – which in our case is the event of ‘testing positive’. Do note, this is what is safe to say; it’s not what may actually be happening on the ground. So by increasing the sample size n as much as possible, ICMR can ascertain with higher and higher confidence as to whether the corresponding group has community transmission or not.
Thus far, ICMR has said there is no community transmission in India based on these calculations. Independent experts have been reluctant to take its word, however, because while ICMR has publicised what the sample size and the number of positives are, there is very little information about two other things.
First: we don’t know how ICMR selected the samples that it did for testing. While the virus’s distribution in the population can be considered to be random, especially if community transmission is said to have commenced, the selection of samples needs to have an underlying logic. What is that logic?
Second: we don’t know the group sizes. It’s important for the sample size to be proportionate to the group size. So without knowing what the group size underlying each sample is, it becomes impossible to tell if ICMR is doing its job right.
On March 17, one ICMR scientist said that some testing centres had admitted fewer people with COVID-19-like symptoms and the source of whose infections was unknown (i.e. community transmission) than the size of the sample chosen from their corresponding group. She was suggesting that ICMR’s choice of samples from each group was large enough to not overlook community transmission. To translate in terms of the example above: she was saying ICMR’s subset size was big enough to catch at least one yellow fleck – and didn’t.
As it happens, on March 20, ICMR announced that it would begin testing for a potential type of community-transmission cases even though its sampling exercise had produced 1,020 negative results in 1,020 samples (distributed across 51 testing centres).
The reasons for this are yet unclear but suggests that ICMR suspects there is community transmission of the virus in the country even though its methods – which ICMR has always stood by – haven’t found evidence of such transmission. This in turn prompts the following question: why not test for all types of community transmission? The answer is the same as before: ICMR has limited resources but at the same time has been tasked with discovering how many yellow flecks are there in the total population.
The virus is not an intelligent creature. In fact, it’s extremely primitive. Each virus is in its essence a packet of chemical reactions, and when each reaction happens depends on a combination of internal and external conditions. Other than this, the virus does not harbour any intentions or aspirations. It simply responds to stimuli that it cannot manipulate or affect in any way.
The overarching implication is that beyond how good the virus is at spreading from person to person, a pandemic is what it is because of human interactions, and because of human adaptation and mitigation systems. And as more and more people get infected, and their groups verge towards the WHO’s definition of ‘community transmission’, the virus’s path through the population becomes less and less obvious, but at the same time a greater depth of transmission opens the path to better epidemiological modelling.
When such transmission happens in a country like India, the body responsible for keeping the people safe – whether the Union health ministry, ICMR or any other entity – faces the same challenge that ICMR did. This is also why direct comparisons of India’s and South Korea’s testing strategies are difficult to justify, especially of the number of people tested per million: India has nearly 26-times as many people but spends 11.5-times less on healthcare per capita.
At the same time, ICMR isn’t making it easy for anyone – least of all itself – when it doesn’t communicate properly, and leaves itself open to criticism, which in turn chips away at its authority and trustworthiness in a time as testing as this. Demonetisation taught us very well that a strategy is only as good as its implementation.
But on the flip side, it wouldn’t be amiss to make a distinction here: between testing enough to get a sense of the virus’s prevalence in the population – in order to guide further action and policy – and the fact that the low expenditure on public healthcare is always going to incentivise India to skew towards a sampling strategy instead of an alternative that requires mass-testing. ICMR and the Union health ministry haven’t inspired confidence on the first count but it’s important to ensure criticism of the former doesn’t spillover into criticism of the latter as well.
Anyway, the corresponding sampling strategy is going to have to be based on a logic. Why? Because while the resources for the virus to spread exist abundantly in nature (in the form of humans), the human response to containing the spread requires resources that humans find hard to get. Against the background of this disparity, sampling, testing and treatment logics – such as Italy’s brutal triaging policy – help us choose better sampling strategies; predict approximately how many people will need to be quarantined in the near future; prepare our medical supplies; recruit the requisite number of health workers; stockpile important drugs; prepare for economic losses; issue rules of social conduct for the people; and so forth.
A logic could even help anticipate (or perpetuate, depending on your appetite for cynicism) ‘leakages’ arising due to, say, caste or class issues. Think of it like trying to draw a circle with only straight lines of a fixed length: with 200 strokes, you could technically draw a polygon with 200 sides that looks approximately like a circle – but it will still have some discernible edges and vertices that won’t exactly map on a circle, leaving a small part of the latter out. Similarly, using a properly designed technique that can predict which person might get infected and who might not can still catch a large number of people – but the technique won’t catch all of them.
One obvious way to significantly improve the technique’s efficacy as it stands is to account for the fact that more than half of all Indians are treated at private hospitals whereas you can be tested for COVID-19 only at a government facility, and not all VRDLs receive samples from all private hospitals in their respective areas.
Ultimately, the officials who devise the logics must be expected to justify how the combination of all logics can – even if only on paper – uncover most, if not all, cases of the virus’s infection in India.
It appears the SARS-CoV-2 coronavirus has begun local transmission in India, i.e. infecting more people within the country instead of each new patient having recently travelled to an already affected country. The advent of local transmission is an important event in the lexicon of epidemics and pandemics because, at least until 2009, that’s how the WHO differentiated between the two.
As of today, the virus has become locally transmissible in the world’s two most populous countries. At this juncture, pretty much everyone expects the number of cases within India to only increase, and as it does, the public healthcare system won’t be the only one under pressure. Reporters and editors will be too, and they’re likely to be more stressed on one front: their readers.
For example, over the course of March 4, the following sentences appeared in various news reports of the coronavirus:
The Italian man infected 16 Italians, his wife and an Indian driver.
The infected techie boarded a bus to Hyderabad from Bengaluru and jeopardised the safety of his co-passengers.
Two new suspected coronavirus cases have been reported in Hyderabad.
All 28 cases of infection are being monitored, the health ministry has said.
Quite a few people on Twitter, and likely in other fora, commented that these lines exemplify the sort of insensitivity towards patients that dehumanises them, elides their agency and casts them as perpetrators – of the transmission of a disease – and which, perhaps given enough time and reception, could engender apathy and even animosity towards the poorer sick.
The problem words seem to include ‘cases’, ‘burden’ and ‘infected’. But are they a problem, really? I ask because though I understand the complaints, I think they’re missing an important detail.
Referring to people as if they were objects only furthers their impotency in a medical care setup in which doctors can’t be questioned and the rationale for diagnoses is frequently secreted – both conditions ripe for exploitation. At the same time, the public part of this system has to deal with a case load it is barely equipped for and whose workers are underpaid relative to their counterparts in the private sector.
As a result, a doctor seeing 10- or 20-times as many patients as they’ve been trained and supported to will inevitably precipitate some amount of dehumanisation, and it could in fact help medical workers cope with circumstances in which they’re doing all they can to help but the patient suffers anyway. So dehumanisation is not always bad.
Second, and perhaps more importantly, the word ‘dehumanise’ and the attitude ‘dehumanise’ can and often do differ. For example, Union home minister Amit Shah calling Bangladeshi immigrants “termites” is not the same as a high-ranking doctor referring to his patient in terms of their disease, and this doctor is not the same as an overworked nurse referring to the people in her care as ‘cases’. The last two examples are progressively more forgivable because their use of the English language is more opportunistic, and the nurse in the last example may not intentionally dehumanise their patients if they knew what their words meant.
Problematic attitudes often manifest most prominently as problematic words and labels but the use of a word alone wouldn’t imply a specific attitude in a country that has always had an uneasy relationship with the English language. Reporters and editors who carefully avoid potentially debilitating language as well as those who carefully use such language are both in the minority in India. Instead, my experiences as a journalist over eight years suggest the majority is composed of people who don’t know the language is a problem, who don’t have the time, energy and/or freedom to think about casual dehumanisation, and who don’t deserve to be blamed for something they don’t know they’re doing.
But by fixating on just words, and not the world of problems that gives rise to them, we risk interrogating and blaming the wrong causes. It would be fairer to expect journalists of, say, the The Guardian or the Washington Post to contemplate the relationship between language and thought if only because Western society harbours a deeper understanding of the healthcare system it originated, and exported to other parts of the world with its idiosyncrasies, and because native English speakers are likelier to properly understand the relationship between a word, its roots and its use in conversation.
On the other hand, non-native users of English – particularly non-fluent users – have no option but to use the words ‘case’, ‘burden’ and ‘infected’. The might actually prefer other words if:
They knew that (and/or had to accommodate their readers’ pickiness for whether) the word they used meant more than what they thought it did, or
They knew alternative words existed and were equally valid, or
They could confidently differentiate between a technical term and its most historically, socially, culturally and/or technically appropriate synonym.
But as it happens, these conditions are seldom met. In India, English is mostly reserved for communication; it’s not the language of thought for most people, especially most journalists, and certainly doesn’t hold anything more than a shard of mirror-glass to our societies and their social attitudes as they pertain to jargon. So as such, pointing to a reporter and asking them to say ‘persons infected with coronavirus’ instead of ‘case’ will magically reveal neither the difference between ‘case’ or ‘infected’ the scientific terms and ‘case’ or ‘infected’ the pejoratives nor the negotiated relationship between the use of ‘case’ and dehumanisation. And without elucidating the full breadth of these relationships, there is no way either doctors or reporters are going to modify their language simply because they were asked to – nor will their doing so, on the off chance, strike at the real threats.
On the other hand, there is bound to be an equally valid problem in terms of those who know how ‘case’ and ‘infected’ can be misused and who regularly read news reports whose use of English may or may not intend to dehumanise. Considering the strong possibility that the author may not know they’re using dehumanising language and are unlikely to be persuaded to write differently, those in the know have a corresponding responsibility to accommodate what is typically a case of the unknown unknowns and not ignorance or incompetence, and almost surely not malice.
This is also why I said reporters and editors might be stressed by their readers, rather their perspectives, and not on count of their language.
A final point: Harsh Vardhan, the Union health minister and utterer of the words “The Italian man infected 16 Italians”, and Amit Shah belong to the same party – a party that has habitually dehumanised Muslims, Dalits and immigrants as part of its nationalistic, xenophobic and communal narratives. More recently, the same party from its place at the Centre suspected a prominent research lab of weaponising the Nipah virus with help from foreign funds, and used this far-fetched possibility as an excuse to terminate the lab’s FCRA license.
So when Vardhan says ‘infected’, I reflexively, and nervously, double-check his statement for signs of ambiguity. I’m also anxious that if more Italian nationals touring India are infected by SARS-CoV-2 and the public healthcare system slips up on control measures, a wave of anti-Italian sentiment could follow.
