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- Thekkumkara Surendran Nair AnishPublished on: 23 June 2022
- BMJ Open EditorsPublished on: 22 April 2022
- Shaffi Fazaludeen KoyaPublished on: 5 October 2021
- Published on: 23 June 2022Response to rapid response comment received for the article titled" Strategies and challenges in Kerala’s response to the initial phase of COVID-19 pandemic: a qualitative descriptive study"
- Thekkumkara Surendran Nair Anish, Associate professor Government medical college, Thiruvananthapuram
We, the authors of the study "Strategies and challenges in Kerala’s response to the initial phase of COVID-19 pandemic: a qualitative descriptive study." BMJ open11.7 (2021): e051410.
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Web. 05 Oct. 2021, https://bmjopen.bmj.com/content/11/7/e051410, would like to respond to the rapid response published against it. This study was done by a group of medical doctors working in the government health sector (affiliations of authors are given clearly) to bring out results with honesty based on a sound qualitative research design and the proposal was cleared by the Institutional Ethics Committee (Human) of Government Medical College, Thiruvananthapuram, Kerala, India (HEC.NO.03/65/2020/MCT). The protocol of the study which obtained ethics approval was also submitted to editors as a supplementary file during submission to the journal. The study was conducted following COPE guidelines on good publication practice and was reported following the Standards for Reporting Qualitative Research guidelines.
Membership of authors in State Expert Committee on COVID 19 and State Medical Board
It appears to us that the respondent is misleading the readers about the role and responsibility of the “COVID expert committee” and “State Medical Board” of the State of Kerala. The chief executive of the State clearly states “the expert committee is a group of public health professionals and scientists constituted t...We, the authors of the study "Strategies and challenges in Kerala’s response to the initial phase of COVID-19 pandemic: a qualitative descriptive study." BMJ open11.7 (2021): e051410.
Web. 05 Oct. 2021, https://bmjopen.bmj.com/content/11/7/e051410, would like to respond to the rapid response published against it. This study was done by a group of medical doctors working in the government health sector (affiliations of authors are given clearly) to bring out results with honesty based on a sound qualitative research design and the proposal was cleared by the Institutional Ethics Committee (Human) of Government Medical College, Thiruvananthapuram, Kerala, India (HEC.NO.03/65/2020/MCT). The protocol of the study which obtained ethics approval was also submitted to editors as a supplementary file during submission to the journal. The study was conducted following COPE guidelines on good publication practice and was reported following the Standards for Reporting Qualitative Research guidelines.
Membership of authors in State Expert Committee on COVID 19 and State Medical Board
It appears to us that the respondent is misleading the readers about the role and responsibility of the “COVID expert committee” and “State Medical Board” of the State of Kerala. The chief executive of the State clearly states “the expert committee is a group of public health professionals and scientists constituted to guide the government on the evolving situation of Covid 19 by creating a repository of all scientific studies and research happening all over the world”[1]. The expert committee group is constituted of subject experts (Epidemiology, Infectious disease, Microbiology, Virology, Emergency medicine, and palliative care) from various institutions across the state to assimilate available scientific evidence on COVID -19 and provide evidence-based opinions on the prevention and control of COVID-19 pandemic. The committee is rather a scientific group and is not the highest-level decision-making and policy formulating bodies next to political leadership as accused by the reader. The state medical board is constituted of a group of six medical doctors heading various clinical departments of Government COVID hospitals across the state who are directly involved in patient care to provide evidence-based opinions on patient management to the institutional medical boards during the pandemic[2]. Both these are academic bodies that support the State by giving technical information on public health and clinical aspects of COVID-19.
The State of Kerala has constituted many committees of experts at the districts and the State level utilising the available health human resource to provide technical advice and expertise in different aspects of the pandemic, and most of the experts working in the public sector in the field of epidemiology, virology, public health, and clinical medicine, naturally became a part of such groups. The inclusion in State level committee only meant that the authors were recognized as experts in their field. The authors, ARK and TSNA though a part of certain committees of the state, do not hold any leadership role in policy and decision-making. Both the authors (TSNA and ARK) are medical doctors and were co-opted into these committees due to their subject expertise and the authors have been transparent with their area of expertise. The administrative role of SV is given in the affiliation. Also, the competing interest statement incorporating the committees the authors are part of, their roles in the respective committee, and their contribution to the reported article has been provided as a correction to the article to provide better clarity for the readers at present.
Appropriateness of FGDs and IDIs
The aim of our study was to obtain an in-depth understanding of the structures and strategies that helped Kerala in fighting the initial phase of the COVID 19 pandemic using a qualitative study design. For such a research objective and design, the sampling could not be random, and rather a purposive or theoretical sampling as participants had to be chosen purposively based on their involvement in decision-making and implementation of COVID-19 control activities at different levels during the initial phase of the pandemic. The authors finalised purposive sampling after several detailed discussions and sampling was done till data redundancy.
The expert committee is a group of eminent scientists and public health/medical experts as mentioned above working with the objective of appraisal of different strategies adopted at regional and international levels. The expert committee comprises of eleven subject experts from different areas related to COVID 19 and this made the researchers decide on an FGD on the committee members. Nine members excluding the authors of the research were invited to the discussion and seven members consented to be a part of the FGD [FGD1 State COVID-19 expert committee members (SCE1–SCE7)]. The committee is not a group of friends, rather it is a group of professionals working together for a cause. Providing evidence-based opinions based on subject expertise could not mount to have any personal relationship between the committee members and the authors themselves believe that they do not have any. Hence, “none of the authors have a personal relationship with any of the participants” as stated in the manuscript stands true and honest from our side. Also, during the conduct of the research, ARK, SV, and TSNA were not involved in data collection and data analysis which is clearly given in the contributorship statement. As the medical board member has a role in the implementation of COVID 19 treatment guidelines, one of the members of the state-level medical board who is vocal and consented to participate in the research was interviewed for the study. Also, ARK had no role in deciding the participants for the interview and was not a part of data collection or analysis that amounts to the disclosure of any sort of relationship with the participant.
The FGD4, IDI 3and 4 were conducted to understand the strategies, roles and responsibilities, and challenges at the grass-root level. The FGD 4 was conducted in a PHC in the Thiruvananthapuram district of Kerala and the two IDIs were conducted with Health inspectors working in two different districts (Northern district and Sothern district different from Thiruvananthapuram district) to capture the wide range of activities undertaken in the state at the grass-root level. The PHC was identified based on the epidemiological characteristics of the area like the intensity of disease transmission and preventive/containment activities carried out in that particular area. The particular urban PHC caters to a large number of expatriates and reported a large number of cases during the initial phase of the pandemic. Also, under the same PHC, an extensive contact tracing activity was undertaken for an epidemiologically unlinked COVID 19 death reported during the initial phase of the pandemic (later identified), which made the researchers finalise to conduct an FGD with the public health staff of the PHC. Moreover, during the data collection period, another medical doctor was posted in charge of the said PHC to carry out the day-to-day activities of the PHC as TSNA was relieved for COVID 19 outbreak-related activities and duties.
Regarding IDI 8, the Head of the Department of Community Medicine, Government medical college, Thiruvananthapuram is the ex officio and she/he is the state PEID (Prevention of Epidemic and Infectious Diseases) cell coordinator. She/he coordinates the data from all regional PEID cells that function in all government and private apex hospitals of the state to strengthen the surveillance system. The role of PEID cell in such a pandemic is crucial in the surveillance and training of health personnel and hence became one of the participants of the study. The role as head of the Department of Community Medicine, Government Medical College, Thiruvananthapuram was acknowledged for the guidance in the practical feasibility of conducting such a study during the pandemic while maintaining COVID-appropriate behavior. In a small state like Kerala with limited health resources, it is only natural that the experts in the health sector share the same departments or work together.
“The Kudumbashree was conceived as a joint program of the Government of Kerala implemented through Community Development Societies (CDSs) serving as the community wing of Local Governments and are organized under a well-networked Community Based Organization (CBO)”[3]. More than 50% of elected representatives of local self-governments in Kerala are women and a large number of them are active members of the CBO [4]. A person handling both the role of local self-government representative and working in a community organization (Kudumbashree) was interviewed as IDI6. In the manuscript, under the category intersectoral coordination within the theme of participation and volunteerism, the role of community organisation has been described well. “The proactive action of LSGD in social mobilisation along with non-government organisations and self-help groups like Kudumbashree (Kudumbashree is the neighborhood group of women, part of the poverty eradication mission of the government of Kerala and is widely distributed across Kerala) was evident during the pandemic. They were instrumental in ensuring an uninterrupted supply of food to quarantined people, migrant labourers, and the destitute by initiating a ‘community kitchen’ immediately following the lockdown along with public distribution system. Disaster management authority along with LSGD identified unoccupied buildings and converted it to quarantine and treatment facilities.”
The manuscripts based on qualitative methodology are often criticized for too lengthy descriptions and often recommended by critiques to synthesize it in a structured manner to highlight the most relevant results/quotations to enhance readability. We also received a similar comment from one of our reviewers and we as authors also believe it is necessary to present the rich data obtained during the process of research in a concise readable form without losing the relevance and richness. Though direct quotes were not used, the role of local self-government, involvement of community organizations, and community participation at grass root level were well documented in the study result.Administrative affiliation of one of the authors
DPM and District officials directly report to the State Mission Director and Director of Health Services respectively and the author (SV) does not come into the chain of command. The district-level program managers/district officials are decision-makers at the district level for COVID 19-related control activities. Among them, vocal, knowledgeable members were chosen purposively and seven members consented to the study (FGD2 District program managers and district officials (DPM1–DPM4, DO1–DO3). The author SV had no role in deciding the participants of the research and was not a part of the data collection or analysis. The affiliation of author SV is also provided to the readers for transparency. We rather feel that the involvement of administrators in public health research should be encouraged because it will help the State to manage future health issues more efficiently.
So the statements of the respondent, “the interviews were mostly done with colleagues of senior authors (ARK, SV, and TSNA) who serve in same committees or with staff who reported directly to one or the other author, potentially resulting in bias and conflict of interest” and “the authors seem to have ignored interviews they conducted with community organization members and local self-government officials (who may or may not be from the same political ideology of state government) resulting in biased conclusions”, are not factual.
Allegations on underreporting of COVID death and use of Information Technology
Again, the primary objective of this research work was to understand the structures and strategies that helped Kerala in fighting the COVID-19 pandemic during the initial phase (From the first case of reporting on January 30, 2020, to April 2020) and the challenges during that period and how it was tackled. The issues raised by the reader occurred after the initial phase of the pandemic. However, we would like to bring some insights to our readers in this area too.
Regarding COVID 19 death reporting by the state, the allegations raised are based on one-sided media reports. The same media report cited by the respondent to raise these issues clearly states that the State expert committee pinpointed some issues in death reporting thereby validating that the expert committee is a body that responds to data and is not the high-level decision-making body in the state. Also, at present original research data are available, including a recently published article in Lancet on April 2022 on the estimation of excess mortality, which shows that undercounting of COVID mortality is the least in Kerala compared to any other Indian State [5–8].Concerning Information Technology, the respondent is trying to drag the research article into some political controversy on the decision of the government to engage a multinational company in COVID data collection. This was withdrawn by the government when the court raised its concern on the privacy and confidentiality issue of sharing the data and finally didn’t materialise in the state. The findings in our study as quoted by the respondent "the information technology department simplified the surveillance and data management by developing platforms for contact tracing and surveillance" are endorsed by many papers published elsewhere [9,10].
Conclusion
The activities in the state of Kerala during the initial phase of the pandemic were cited as an example to be followed by World Health Organization [11] and were also lauded by United Nations[12]. In addition, ample scientific research articles are available on Kerala’s response to COVID 19 pandemic, which validates our findings[13–23].
In a small state like Kerala, during a pandemic situation, all citizens of the state are working hand in hand to the best of their capabilities using all available resources as a team to curb the curve. This could not mean that all the individuals by being a part of this fight are personally or academically or professionally or financially related. Each individual considers it as a duty to serve their state in this difficult situation. Being academicians primarily in public health/infectious disease and medical doctors (affiliations given including that of the administrator), all authors of this manuscript are bound to serve their state in this crisis within our capacity. This could not account to have a vested interest especially when truly and honestly, we believe that we have reported the results based on a sound methodology adopting all possible measures to maintain scientific rigour. The affiliations provided (that all authors are academicians/medical doctors working in the government health sector of the state) are for the readers to contextualize the research and the subjectivity of the researcher for that matter, to understand that the research is conducted and reported by researchers working within the state and not an external agency.
Also, we would like to take this as an opportunity to enlist the measures adopted during the course of the research (reported in the manuscript and a similar table was also provided during the peer review process of the journal) to ensure validity and reliability and thereby scientific rigour to avoid “enthusiastic scepticism” in the future on the integrity of this manuscript.
Based on Shenton, A. K. (2004). Strategies for Ensuring Trustworthiness in Qualitative Research Projects, the strategies adopted during the course of research (reported in the manuscript) to ensure scientific rigour are as follows.
1. Credibility (in preference to internal validity) - Using well-established research method, triangulation, freedom for participants to refuse the invitation or withdraw from the study at any time, use of probes to elicit detailed data, rigorous discussion among the researchers, and sharing of final results with the participants thereby ensuring the accuracy of the data. And finally, congruence of the project’s results with an existing body of knowledge, which is often considered as the key criterion for evaluating qualitative work. The article titled “Responding to COVID-19 - Learnings from Kerala was published on the site of the World Health Organisation in July 2020 and cited in the manuscript.
2. Transferability (in preference to external validity/generalisability)- A rich description is provided in the result part for the readers to understand and reflect on.
3. Dependability (in preference to reliability) - The process of the study was provided in detail with the participant list and interview guide in the methodology part.
4. Confirmability (in preference to objectivity) - Triangulation of data sources- the participants were chosen from the department of health and family welfare, the police, revenue, local self-government (LSGD), and community-based organisations: and thereby use a wide range of informants from subject experts to grass root level implementing staff. Use of different methods- Focus group discussions and in-depth interviews.References
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1. https://www.thehindu.com/news/national/kerala/expert-committee-to-guide-....
2. https://dhs.kerala.gov.in/wp-content/uploads/2020/03/mb_05022020.pdf.
3. https://www.kudumbashree.org/ Kudumbashree: State poverty eradication mission, Govt of Kerala.
4. Devika J. The ‘Kudumbashree woman and the Kerala model woman: Women and politics in contemporary Kerala. Indian Journal of Gender Studies. 2016 Oct;23(3):393-414.
5. COVID-19 Excess Mortality Collaborators. Estimating excess mortality due to the COVID-19 pandemic: a systematic analysis of COVID-19-related mortality, 2020-21. Lancet. 2022 Apr 16;399(10334):1513-1536.
6. Raina SK, Kumar R. Kerala & Mizoram; High COVID-19 case load but low mortality: Role of precautionary principles. J Family Med Prim Care. 2022 Feb;11(2):415-417.
7. Rath RS, Dixit AM, Koparkar AR, Kharya P, Joshi HS. COVID-19 pandemic in India: A Comparison of pandemic pattern in Selected States. Nepal J Epidemiol. 2020 Jun 30;10(2):856-864.
8. Azarudeen MJ, Aroskar K, Kurup KK, Dikid T, Chauhan H, Jain SK, Singh SK. Comparing COVID-19 mortality across selected states in India: The role of age structure. Clin Epidemiol Glob Health. 2021 Oct-Dec;12:100877.
9. Ummer O, Scott K, Mohan D, Chakraborty A, LeFevre AE. Connecting the dots: Kerala’s use of digital technology during the COVID-19 response. BMJ Glob Health. 2021 Jul;6(Suppl 5):e005355.
10. S J, Sreedharan S. Analysing the Covid-19 Cases in Kerala: a Visual Exploratory Data Analysis Approach. SN Compr Clin Med. 2020;2(9):1337-1348.
11. https://www.who.int/india/news/feature-stories/detail/responding-to-covi....
12. https://timesofindia.indiatimes.com/city/thiruvananthapuram/kerala-healt....
13. Sadanandan R. Kerala’s response to COVID-19. Indian J Public Health. 2020 Jun 1;64(6):99.
14. Kaim K, Ahirwar AK, Ahirwar P, Sakarde A. Kerala model for combating COVID-19 pandemic. Horm Mol Biol Clin Investig. 2021 Feb 12;42(1):1-2.
15. Mustafa S, Jayadev A, Madhavan M. COVID-19: Need for Equitable and Inclusive Pandemic Response Framework. Int J Health Serv. 2021 Jan;51(1):101-106.
16. Chandra R, Sinha S. India Fighting COVID-19: Experiences and Lessons Learned From the Successful Kerala and Bhilwara Models. Disaster Med Public Health Prep. 2021 Apr 19:1-5.
17. Menon JC, Rakesh PS, John D, Thachathodiyl R, Banerjee A. What was right about Kerala’s response to the COVID-19 pandemic? BMJ Glob Health. 2020 Jul;5(7):e003212.
18. Dutta A, Fischer HW. The local governance of COVID-19: Disease prevention and social security in rural India. World Dev. 2021 Feb;138:105234.
19. Rahim AA, Chacko TV. Replicating the Kerala State’s Successful COVID-19 Containment Model: Insights on What Worked. Indian J Community Med. 2020 Jul-Sep;45(3):261-265. doi: 10.4103/ijcm.IJCM_598_20.
20. Sarkar S. Breaking the chain: Governmental frugal innovation in Kerala to combat the COVID-19 pandemic. Gov Inf Q. 2021 Jan;38(1):101549.
21. Thiagarajan K. Covid-19: How Kerala kept itself above water in India’s devastating second wave. BMJ. 2021 Aug 19;374:n2005.
22. Pandi-Perumal SR, Gulia KK, Gupta D, Kumar VM. Dealing with a pandemic: the Kerala Model of containment strategy for COVID-19. Pathog Glob Health. 2020 Jul;114(5):232-233.
23. M A S, Pande N, P K SK. Role of effective crisis communication by the government in managing the first wave Covid-19 pandemic - A study of Kerala government’s success. J Public Aff. 2021 Jul 23:e2721.Conflict of Interest:
The author is the corresponding author of the article title" Strategies and challenges in Kerala’s response to the initial phase of COVID-19 pandemic: a qualitative descriptive study" - Published on: 22 April 2022Editors' Note
- BMJ Open Editors, Editorial team BMJ Open
BMJ Open thanks the author of the posted response for their comments.
We have published a Correction notice with an updated Competing Interests statement provided by the authors. This Correction can be viewed here: https://bmjopen.bmj.com/content/12/3/e051410corr1
Conflict of Interest:
This post was made by the staff editors of BMJ Open. - Published on: 5 October 2021Some critical questions on research and publication ethics
- Shaffi Fazaludeen Koya, Research Fellow Boston University School of Public Health, Boston, MA, USA
The recently published research paper on strategies and challenges in Kerala's response to the initial phase of the COVID-19 pandemic by Prajitha et al. (1) throws up some critical questions on research and publication ethics. All the three senior authors of the paper are part of the senior administrative and technical leadership of the State covid response. Two of them are members of the “state expert group on Covid”, one is a member of both the state medical board and the state level death audit team, and the corresponding author himself is the convener of the state expert group. (2-5) Obviously these are the highest-level decision making and policy formulating bodies next only to political leadership. While it is encouraging and often required for senior administrators and academicians in government positions to conduct such studies and publish such research papers, they need to be transparent about their involvement in policy and decision making when reporting such research findings, and unbiased when interpreting the results and making conclusions. This is especially important in case of research outputs such as this one, which should ideally serve as records of what has been done and what has not been during the pandemic. Let us examine some of the issues.
First, of the four FGDs listed, one was conducted among State COVID-19 expert committee members. (1) Whereas the authors report "the researchers had no personal relationship with the participants,...
Show MoreThe recently published research paper on strategies and challenges in Kerala's response to the initial phase of the COVID-19 pandemic by Prajitha et al. (1) throws up some critical questions on research and publication ethics. All the three senior authors of the paper are part of the senior administrative and technical leadership of the State covid response. Two of them are members of the “state expert group on Covid”, one is a member of both the state medical board and the state level death audit team, and the corresponding author himself is the convener of the state expert group. (2-5) Obviously these are the highest-level decision making and policy formulating bodies next only to political leadership. While it is encouraging and often required for senior administrators and academicians in government positions to conduct such studies and publish such research papers, they need to be transparent about their involvement in policy and decision making when reporting such research findings, and unbiased when interpreting the results and making conclusions. This is especially important in case of research outputs such as this one, which should ideally serve as records of what has been done and what has not been during the pandemic. Let us examine some of the issues.
First, of the four FGDs listed, one was conducted among State COVID-19 expert committee members. (1) Whereas the authors report "the researchers had no personal relationship with the participants," a potential conflict of interest can be easily noted as the two senior authors are themselves part of the State Covid expert group. (3, 5) It’s surprising that while the authors note “the possibility of a positive bias in highlighting the efficiency of the system cannot be excluded as the majority of the respondents were within the government system”, they ignored to disclose their own authors’ bias. Second, a state medical board member was interviewed (IDI1) in the study, while one of the senior authors is himself a member of the state medical board. This amounts to non-disclosure of relationship and conflict of interest. (4) Third, the study reports one FGD (FGD4) and two IDIs (IDI3, IDI4) among field-level health staff of a primary health center. All the respondents in these FGDs and IDIs technically and administratively reported on a day-to-day basis to the corresponding author as he was the administrative medical officer in charge of the primary health center during the data collection period. (6) Fourth, an FGD was conducted with district program managers and district officials (FGD2), who technically and administratively report to one of the senior authors who is also an Indian Administrative Service official in charge of the COVID-19 pandemic management in Kerala. (7,8) Fifth, the authors acknowledge the guidance of the head of the Department of Community Medicine, Government Medical College, Thiruvananthapuram for the study, who, incidentally, is also one of the respondents in the study- the State PEID cell coordinator (IDI 8). (2,9) On the other hand, the paper says community organization members were interviewed, but we do not see them in the interviewee list, nor do we see any findings or statements attributed to any such person. Similarly, local self-government officials were reportedly interviewed, but apparently, nothing was reported based on those interviews. All these show that the authors selectively relied on perceptions and opinions of their co-workers in the same government committees or their subordinate staff members for this study. As per ICMJE standards, the integrity of the entire research may be compromised by such an inappropriate methodology. (10)
From a research ethics perspective, the authors, and more specifically the corresponding author had an obligation to disclose their affiliations with different COVID 19 committees of the government. (10) Such a disclosure would have helped the readers contextualize the research paper better, especially when the paper concludes with such sweeping statements as this one- "the model can serve as an example for other states and nations to emulate or adjust accordingly." Moreover, the latest ICMJE recommendations emphasize that “purposeful failure to report those relationships or activities” is a form of scientific misconduct. (10) A transparent disclosure by authors is essential to help readers to decide whether authors’ relationships are “pertinent to a paper’s content” and is required to maintain trust in the scientific process.
Understandably, the paper was published a year later though the data were collected during May-August 2020. However, with the evolving pandemic, much had happened during those 12 months. There were at least two great learnings for the State and on a global perspective had the researchers been more objective in their approach.
The first learning is related to transparency. The authors report in the paper that "the vertical and horizontal integration made the state's administrative system more transparent and acceptable to the people." Though it’s not clear the source of data on which this conclusion/observation is made, the authors should not have missed the sharp criticism from the public, including relatives of the deceased Covid patients, besides the doctors, public health experts, medical association, and even members of the expert committee around under-reporting of deaths by the state even during the data collection period. (11-13) In fact, a group of health activists and engineers took the pain to crowdsource data and document all the actual Covid deaths (14) but was forced to drop the effort in between as the government stopped furnishing the details in the public domain. On the contrary, the State denied all the allegations as "wrong information" without providing any substantial evidence through an evasive discussion paper which stated that the state medical board and death audit committees used scientific methods of death auditing. (15) Strangely, none of these things pertinent challenges were mentioned even in the discussion session though the article was published recently, and the authors reported the use of “probes” to “avoid bias”. (1) One of the authors of this paper is a member of both these committees. (2,4) At the minimum, this may be interpreted as bias and poor reflexivity by the authors, if not intellectual and academic dishonesty. However, such inappropriate methodology would compromise the research integrity. (10)The second learning is related to data handling, privacy, and confidentiality. The paper claims, "the information technology department simplified the surveillance and data management by developing platforms for contact tracing and surveillance." However, there is critical learning on the surveillance, which missed the narrative. During the study period, the state government came under heavy criticism for engaging a private foreign agency to handle the data of Covid patients and those under quarantine without proper consent process and without anonymizing the data. (16) When the matter came to the court, the government initially defended its decision citing a lack of local technical capacity for data handling, but in the very next court hearing, the government informed that the private agency contract is canceled and that a state agency itself will handle the data. (17) Though it may be separately debated whether there was actual breach of confidentiality and data privacy, the whole episode could have been an excellent lesson to "transcribe and assimilate, not only for the state and the nation but also on a global perspective," as the authors claim elsewhere. Surprisingly, none of these issues came up in the interviews with any of the stakeholders (or are not reported in the paper), which raises doubts about the veracity of the findings or at least the inappropriateness and inadequacies of the study method. Finally, coming to the challenges of Kerala’s response identified by the authors, we see an unfortunate authoritarian pattern to blame the public and hide any systemic issues. While trying to substantiate that the State was a victim to initial success, the authors say: "people failed to recognize the seriousness of the situation when all services were provided free of cost." This is not just condescending but also domineering.
To summarize, there are three critical observations. First, the authors failed in their obligation to reveal the competing interests and declaration of relationship and activities many of them had- being part of different Covid management decision-making bodies in the State government- thereby denying the readers an opportunity to reflect on the findings better. Second, the interviews were mostly done with colleagues of senior authors who serve in same committees or with staff who reported directly to one or the other author, potentially resulting in bias and conflict of interest. Third, the authors seem to have ignored interviews they conducted with community organization members and local self-government officials (who may or may not be from the same political ideology of state government) resulting in biased conclusions. By this inappropriate methodology, the integrity of research is compromised. While the authors are free to defend government actions through opinion pieces or newspaper columns, a peer-reviewed research article needs to be more objective (methodologically) and transparent.
Reference:
1. BMJ Open 2021;11:e051410. doi: 10.1136/bmjopen-2021-051410
2. Government of Kerala. COVID19 Death audit report June 2020 (page 21, annexure B). Accessed Oct 23, 2021, from https://dhs.kerala.gov.in/wp-content/uploads/2020/07/Death-Audit-Report-...
3. Government of Kerala. Constitution of Expert Group -COVID 19 - constitution of the Expert Group- Orders issued. G.O.(Rt)No.616/2020/H&FWD (File no. HEALTH-F2/122/2020-HEALTH) dated, Thiruvananthapuram, 20/03/2020; Accessed Oct 23, 2021, from https://eoffice.kerala.gov.in/EofficePortal/gosearch.action searched using date and GO number.
4. Government of Kerala. Constitution of State Medical Board. Dated 2 Feb 2020. Accessed Oct 22, 2021, from https://dhs.kerala.gov.in/wp-content/uploads/2020/03/mb_05022020.pdf
5. Government of Kerala. Constitution of Expert Group -COVID 19 - constitution of the Expert Group- Addendum -Orders issued. G.O.(Rt)No.622/2020/H&FWD (File no. HEALTH-F2/122/2020-HEALTH) dated, Thiruvananthapuram, 20/03/2020; Accessed Oct 23, 2021, from https://eoffice.kerala.gov.in/EofficePortal/gosearch.action, searched using date and GO number.
6. Pangappara PHC. Sanitation certificate issued by the medical college health unit (PHC), Pangappara counter signed by the corresponding author. Accessed Oct 24, 2021.http://www.sabarigiriinternationalschool.com/wp-content/uploads/2021/04/...
7. Government of Kerala. Civil list of Indian Administrative Service officers (Kerala cadre) as on 04.06.2020. Serial No. 102.http://www.gadsplais.kerala.gov.in/images/pdf/IAS(Kerala%20Cadre)CivilList_2020.pdf, Accessed on 21 Oct 2021.
8. Kerala Kaumudi. Sriram Venkitaraman reinstated into service, in charge of COVID-19 preventive activities. Keralakaumudi Daily. Published March 22, 2020. Accessed October 23, 2021. https://keralakaumudi.com/en/news/news.php?id=268449&u=sriram-venkitaram...
9. Government of Kerala. Technical paper on COVID 19 Rapid Anti Body Test sero-surveillance -Base line Report, Kerala (page 5, committee members). Accessed on 21 Oct 2021 from https://arogyakeralam.gov.in/wp-content/uploads/2020/03/Technical-paper-...
10. ICMJE. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals.; 2015Accessed October 24, 2021. http://www.icmje.org/icmje-recommendations.pdf
11. Mathew A. Kerala undercounts COVID-19 deaths after changing criteria for the kinds of deaths to be included in list. National Herald. Published August 14, 2020. Accessed October 1, 2021. https://www.nationalheraldindia.com/india/kerala-undercounts-covid-19-de...
12. The News Minute. Kerala's ambiguous reporting of COVID-19 deaths is concerning: Medical experts. The News Minute. Published August 24, 2020. Accessed October 5, 2021. https://www.thenewsminute.com/article/kerala-s-ambiguous-reporting-covid...
13. Maya C. Coronavirus | COVID-19 death audit report of Kerala raises eyebrows. The Hindu. Published August 30, 2020. Accessed October 24, 2021. https://www.thehindu.com/news/national/kerala/covid-19-death-audit-repor...
14. Soutik Biswas. India coronavirus: How a group of volunteers "exposed" hidden Covid-19 deaths. BBC News. Published November 20, 2020. Accessed October 5, 2021. https://www.bbc.com/news/world-asia-india-54985981
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16. NDTV. Coronavirus - Kerala Must Take Consent Before Sharing COVID-19 Data With US Firm: Court. NDTV.com. Published April 24, 2020. Accessed October 24, 2021. https://www.ndtv.com/kerala-news/coronavirus-kerala-must-take-consent-be...
17. Jeemon Jacob. Kerala backs out of Sprinklr deal, cancels controversial pact over privacy issues. Published May 21, 2020. Accessed October 5, 2021. https://www.indiatoday.in/india/story/kerala-sprinklr-deal-covid-19-pina...Conflict of Interest:
None declared.