At the end of each year, it is customary for the editorial team to provide an annual
report to the Journal readership and outline plans for the next year. This transition
from 2020 to 2021 feels vastly different from other years, however, and the annual
tradition takes on a greater significance. A year ago, when I penned my editorial
for the first Journal issue of 2020 (Tandon, 2020a) and articulated ambitious plans,
little did I know of the calamitous year to follow and the devastation that a viral
pandemic would inflict on the entire world. Through all of 2020, the lives of planet
Earth’s 7.84 billion human inhabitants were turned topsy-turvy, albeit in different
ways and to varying extents. Although the first known case occurred in late 2019 and
the disease received the name COVID-19 in February of 2020, it was not until the middle
of March that the global scale of the infection was recognized and the World Health
Organization declared it a pandemic. Since that time, over 82 million people have
been infected with the SARS-CoV-2 virus and over 1.8 million have died from COVID-19.
In an effort to control the spread of this contagion, lockdowns and quarantines were
routine across the world, schools and colleges shut down, workplace closures frequent,
stay-at-home restrictions widely implemented, and marked restrictions placed on all
forms of travel and public gatherings. The world economy plummeted into its deepest
recession in the modern era. Although there are some hopeful signs with an improved
understanding of how to reduce contagion and the arrival of effective vaccines, the
pandemic continues to wreak havoc with over 500,000 new infections and over 10,000
COVID-related deaths across the world every day.
As we bid 2020 good-bye and start a new year with a mixture of hope and trepidation,
it is a good time to take stock. What happened? What did we do and how did we fare?
What have we learned? Given the fact that COVID-19 continues to ravage our world,
what should we do differently and what can we do better? It is prudent to examine
these issues at a global level as also answer these questions more narrowly in terms
of mental health and our profession and then more specifically with reference to our
Journal. To be sure, the Journal was significantly impacted by the pandemic and its
impact on mental health and the practice of psychiatry. The Journal experienced a
four-fold increase in the number of submissions from 1,000 in the year 2019 to almost
4,000 in the year 2020. Of the 583 published articles in the year 2020, 227 (39 percent)
were related to COVID-19 and mental health, a topic that did not exist prior to this
year. In a March editorial (Tandon, 2020b), we had committed that the Asian Journal
of Psychiatry would strive to play its role in the dissemination of good information
relevant to COVID-19 and mental health. We did not realize how challenging that task
would be. In an international healthcare crisis such as the COVID-19 pandemic, real-time
dissemination of accurate information becomes critical in order to enable optimal
healthcare and policy decision-making in a situation of urgency with substantial uncertainty,
compelling the Editor to adjust the balance between comprehensive and speedy manuscript
processing in order to make valid information available expeditiously (Tandon, 2020c).
Over 2,000 submissions on the topic over a 9-month period strained our capacity and
a large number of the manuscripts were of variable quality and relevance. Authors
of potentially useful but preliminary or opinion-laden submissions were asked to condense
their manuscripts into a more concise format such as Correspondence; the objective
was to inform the readership of the less definitive nature of the contribution. We
recognized that publishing a large number of Letters to the Editor would have downstream
negative effects on Journal prestige such as lowering our Impact Factor (currently
2.53), but believed that this was the right course of action. The need for ultra-rapid
manuscript processing and the relatively speedy publication of accepted manuscripts
had predictable effects- many desirable and some less desirable. We published 227
articles on COVID-19 and mental health, significantly focused on contributions from
and implications for countries in Asia. These publications included contributions
from authors across 30 different Asian countries. Nine of the most highly cited articles
on COVID-19 and mental health were published in our Journal (Ahmed et al., 2020; Banerjee,
2020; Goyal et al., 2020; Mamun and Griffith, 2020; Rajkumar, 2020; Roy et al., 2020;
Tandon, 2020a,b, Zandifar and Badrfam, 2020); each of these has been cited over 100
times in the scientific literature. Less desirable consequences include the publication
of a substantially larger volume of Correspondence and the inability to provide more
detailed feedback to authors whose submissions were not accepted for publication.
The Journal is making some necessary corrections and implementing plans first laid
out at the beginning of 2020. While these changes and plans will be discussed in detail
in the next editorial, let us examine how COVID-19 affected people around the world,
how nations responded to it, what differences were observed in outcomes across the
world with a particular focus on countries in Asia.
1
What Happened?
COVID-19 was a once-in-a-century pandemic in terms of the breadth and magnitude of
its impact on mankind. What are the facts as we know them:
a)
As of today, there have been over 82 million confirmed cases and 1.8 million deaths
associated with COVID-19 across the world.
b)
Although the pandemic originated in Asia (Wuhan, the capital city of the Hubei province
in China), it disproportionately impacted countries in Europe and the Americas. With
58 percent of the world’s population, Asia accounts for 25 % of the confirmed cases
and 19 % of the worldwide mortality associated with COVID-19. In contrast, Europe
has 9 percent of the world’s population but 28 percent of both confirmed cases and
COVID-19 associated deaths. The United States of America has 4 percent of the world’s
population but 25 percent of the world’s cases and 19 percent of COVID-19 related
deaths around the world.
c)
In Asia, India has the largest number of confirmed cases (10 million) and COVID-19
related deaths (150,000) as of date. With a population of 1.35 billion (17 percent
of the world’s population), it accounts for 12 percent of confirmed cases and 8 percent
of COVID-19 associated deaths around the world.
d)
Across Asia, there is significant variation in density of reported cases (total cases/100,000
population) and COVID-19 related deaths (deaths/100,000). Countries in the middle
east (Bahrain, Iran, Israel, Jordan, Kuwait, Palestine, Qatar) and those bordering
Europe (Armenia, Azerbaijan, Cyprus, Turkey) have the highest number of reported cases
and COVID-19 associated deaths per unit population.
e)
China, where COVID-19 originated, officially reports a total of 87,000 confirmed cases
and 4,600 COVID-19 associated deaths. A recent report, however, suggests that there
had likely been over 500,000 cases in Wuhan itself.
f)
The world witnessed negative economic growth, with the gross domestic product of most
countries shrinking. China and a few countries in East Asia were notable exceptions.
g)
Although the SARS-CoV-2 virus and resultant COVID-19 disease were identified in Wuhan
city in December, 2019, the world was not apprised about this until late January,
2020 and it took another two months for the World Health Organization to declare it
a pandemic. All through this pandemic, international organizations such as the WHO
have played a very limited role.
h)
Although we are into a new year, COVID-19 is still very much with us. Across the world,
we still document over 500,000 new cases and 10,000 COVID-19 related deaths every
day. Asia accounts for approximately 15 percent of these new cases and deaths, while
the USA and Europe each account for 30–40 percent.
i)
Multiple vaccines against the virus have been developed and approved. These are being
rolled out across the world, although not in any coordinated manner. As of today,
approximately 20 million individuals have received at least one dose of one of these
vaccines; it should be noted that most of these vaccines require two spaced-out doses
to be fully effective and our global population is 7,835 million people.
2
What can we learn from these facts?
Before we attempt to make sense of what has happened and draw lessons about what we
can do better, it is important to first consider the veracity and relevance of these
observations. Comparison of statistics across countries is problematic because of
differences in methods of ascribing deaths to COVID-19, differences in rates of testing
for SARS-CoV-2 infection, varying quality of data collection and aggregation, and
questions about the accuracy of official reporting across countries. Despite these
limitations, however, these are the facts we have. What do they tell us?
A) Relatively Better Outcome in Asia
Despite its origins in Asia, Europe and the Americas have been much more severely
impacted by the COVID-19 pandemic, both in health and economic terms. Furthermore,
the significantly poorer socio-economic conditions and less developed healthcare system
should have predicted a greater impact in Asia. Finally, the much higher population
density and large number of slums in Asia, physical distancing should have been much
more difficult and that should have enabled easier spread of the virus there. How
then does one interpret the relatively better outcomes in Asia as compared to Europe
and the Americas?
(i)
The younger average age of populations in most Asian countries compared to Western
Europe and, to a lesser extent, the USA maybe one factor leading to lower mortality
rates in Asia. But that cannot explain the significantly lower rates of confirmed
cases. What did the richer countries with much better healthcare systems do wrong?
(ii)
Containment strategies with isolation and contact tracing were much more vigorous
across Asian countries than in most European countries and the United States. Even
among Asian countries, efforts were more robust in East Asian countries than those
in South and West Asia. The presence of a national healthcare system and a greater
degree of state authority and control appear to be important determinants. What should
the balance between individual freedom and privacy on the one hand and greater governmental
powers be?
(iii)
Across all countries, the elderly and those with comorbid chronic medical illnesses
had the highest mortality. The disadvantaged (poor, minorities, migrants, etc.) in
most countries had significantly worse outcomes- disparities in outcomes within nations
often underlined existing disparities in health and healthcare. Amidst the increasing
nationalism and majoritarianism across the world, how can minorities and migrants
be better protected? With the shift to market-based capitalism across the world, how
can the poor and other disadvantaged and vulnerable populations be better served?
(iv)
The speed with which vaccines were developed has been spectacular. Multiple different
vaccines have been developed and approved- USA (Biontech-Pfizer, and Moderna) and
the United Kingdom (Oxford-AstraZeneca); both these are more individualistic and market-based
economies with greater transparency and stronger incentives for entrepreneurship.
(v)
Vaccines have also been developed in three Asian countries (China, India, and Russia)
and are being distributed across the world. Despite the rapidity with which effective
vaccines were developed, when the world’s population will receive them is uncertain.
So far, fewer than 20 million individuals have received a dose of the vaccine- that
is 0.025 percent of the world’s population! Will vaccine distribution be swift and
equitable? Will its administration be efficient?
(vi)
The role of the World Health Organization has been widely criticized and it is considered
to have been ineffective in coordinating an effective global response to the pandemic.
This global organization does not, however, have any intrinsic authority or power
and only has the limited powers ceded to it by individual sovereign nations. How can
the authority and abilities of trans-national global organizations be enhanced?
B) Some Lessons to Learn
The pandemic exposed weaknesses in our public health preparedness and structure of
our healthcare systems. We learned that we are all vulnerable and must share the global
responsibility of addressing the worldwide shared vulnerability to infectious diseases
with pandemic potential. We must recognize our common vulnerability, our weak existing
global outbreak surveillance system, and virtues of an integrated global response.
We need effective international organizations that are empowered to coordinate across
nations. Accurate information needs to be shared across nations and mechanisms to
enable this need to be strengthened. The focus needs to be on collective problem-solving
and not in blaming and shaming. Accuracy of message should not be sacrificed at the
altar of “controlled messaging” driven by nationalistic or political objectives. All
of us have an important responsibility to combat conspiracy theories and rumors while
promoting dissemination of accurate information of what we know, what we don’t know,
and what this information means. The pandemic has also exposed glaring health disparities
and this should provide an impetus for reducing such inequities.
We cannot solve our problems with the same thinking we used when we created them-
Albert Einstein