Lancet on India

Despite a strong response at the outset of the pandemic, as of Sept 22, India has the world's fastest growing outbreak of COVID-19 in absolute numbers according to WHO, reporting more than 5·6 million infections. Restrictions began to be lifted in June, and this relaxation has continued in the face of a continuing dramatic increase in case numbers nationally. Beneath these alarming national figures, the pattern of spread in India is nuanced and complex, with marked differences between states, and between rural and urban areas. For example, cities like Kolkata and rural areas in the north of India were relatively spared the outbreak initially, whereas Delhi, with strong international connections, was at the forefront of the first wave. Even so, India is clearly facing a dangerous period.
The country has responded well in many regards, especially for such a large and diverse nation. India instigated a national lockdown in March, which was praised by WHO. During the lockdown period, tertiary care provision was increased, including access to specialist equipment such as ventilators. Testing numbers also increased quickly, with India being among the first to roll out innovations like pooled testing. India has also been at the forefront of efforts to develop and manufacture a vaccine, both through domestic vaccine candidates and manufacturers such as the Serum Institute of India preparing production capacity for internationally developed vaccine candidates.
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Difficulties remain. The lockdown created a parallel crisis for many people as income fell dramatically, hunger increased, and many migrant workers walked long distances home. India's GDP was already decreasing before COVID-19 but the contraction of almost 25% year on year in the quarter April to June could make India one of the worst affected countries economically. As the outbreak has spread from its initial foothold in cities to smaller urban areas and villages, pre-existing disparities in health-care provision have become increasingly relevant. Rural health infrastructure in India can be sparse, and some smaller private hospitals have reported equipment shortages, especially oxygen.
Most crucially, the rapidly growing case numbers, alongside the continuing relaxation of restrictions, are creating an atmosphere of fatalism mingled with false optimism that undermines effective use of non-pharmaceutical interventions such as masks and physical distancing. The epidemic in India is far from over, with a potentially huge burden of mortality and morbidity to come unless public health measures are used and adhered to. Without clear and honest communication of the risks of COVID-19 to the population, stemming the epidemic will be impossible.
According to news reports, hours before announcing the national lockdown, Prime Minister Narendra Modi told owners and editors from India's largest media organisations that it was important to tackle the spread of pessimism, negativity, and rumour. This pressure to avoid negative news, and to offer reassurance, appears to have been felt by several professional scientific organisations in India. The Indian Council of Medical Research (ICMR) has been singled out by experts for straying from scientific evidence, appearing at worst politically motivated and at best overly optimistic. A letter from the Director General of the ICMR, Balram Bhargava, said that the ICMR envisaged launching a coronavirus vaccine on Aug 15 (Indian Independence Day; a deadline considered unrealistic by most medical experts); ICMR has supported treatment with hydroxychloroquine despite insufficient evidence; and news reports claim that data on coronavirus infection were removed from a scientific paper.
Transparency of the data on COVID-19 cases and deaths, especially those underpinning the case fatality rate, has also been questioned, as detailed in a recent World Report. The Indian Government reports a case fatality rate of 1·8%, much lower than the reported rate in other countries, but it is difficult to know if the numbers are comparable.

Hope is important, and recognising successes is vital, especially during a pandemic. But presenting the current situation in India with a too positive spin not only clouds reality but also hampers vital public health initiatives. Perpetuating unrealistic claims or failing to honestly report negative news creates uncertainty among the public and health-care professionals, discouraging people from taking preventive action or taking public health messages seriously. India has the expertise in medicine, public health, research, and manufacturing to lead the nation through the COVID-19 pandemic. To capitalise on these attributes, the country's leaders must respect scientific evidence, expert commentary, and academic freedom, and not provide false optimism. more