‘COVID Will Set Back India’s TB Programme By A Decade’

Mumbai: India will be lucky if it ends tuberculosis by 2035--a decade later than targeted--says Madhukar Pai, Canada Research Chair in epidemiology and global health and director of the McGill International TB Centre in Montreal, Canada, pointing to an 80% drop in monthly notifications of TB because of COVID-19-related disruptions.

As India emerges from lockdown in phases, the healthcare system will see a “big surge” of patients such as those with more severe tuberculosis, uncontrolled hypertension and diabetes, and mild heart attacks that have been ignored due to COVID-19-related disruptions, says Pai, adding that the government needs to rope in India’s private health sector and pay them a fair tariff to overcome the crisis, Pai said.

While a differentiated lockdown strategy based on the spread of the disease is desirable, testing needs to be ramped up massively for this to be efficient, says Pai, who did his medical training and community medicine residency in Vellore, Tamil Nadu, and also did his PhD in epidemiology from the University of California in Berkeley.

Edited excerpts: 

It is a Hobson’s choice. We have to emerge from this lockdown, because, among other things, we have been in it for too long; and secondly, we know that we are going to be faced with some very difficult conditions and situations as we do, given the fact that the number of COVID-19 cases are rising even as we speak.

It is an incredibly tough choice, not just for India; every country is pretty much struggling with it. Take America for example. They are easing restrictions even as their cases continue to climb day after day. [It is the] same thing in my province in Canada, Quebec--cases continue to rise every day, and yet the province is planning to lift restrictions. When your cases are rising and you remove restrictions such as physical distancing, everybody is worried about the surge in cases again. We may have to go through multiple peaks and troughs before anything can really happen, because there is no vaccine on sight, in the immediate future--definitely not for this year. So, what do we then do?

For countries like India, the lockdown has been brutal, especially for the millions of people who live below the poverty line. If they do not work that day, they do not eat that day. So, I completely understand the importance of lifting restrictions. The WHO [World Health Organization] has listed six criteria that countries have to have in place before they can ease restrictions. India definitely does not meet many of the criteria, and yet India is going ahead. The same could apply for the US, for example, for that matter. For example, you need a lot of testing capacity, to be able to keep track of the virus. They talk about the package of “test, trace, and isolate”. That requires incredible capacity for a country of 1.3 billion people and India’s testing rates are very low right now, which means we simply do not know how widespread this epidemic is. We do not have serological surveys to know what proportion of Indians are already infected. 

I think what will work in India’s favour, and I hope this is true, is that the young population structure will somehow push the disease severity towards milder forms or asymptomatic forms, and I am hoping that would somehow carry us through. But India has to absolutely increase capacity for testing, tracing and isolating, handwashing, preventing large gatherings like movie theatres, stadiums. I think those are all common sense approaches that India absolutely can do.

And also, the differentiated strategy--which I am happy to see is already happening--that you do not have to lock down a place that is hardly reporting any cases. You focus your efforts more on those pockets where there is a lot of confirmation and find a way to intensely engage in that area. But that implies that you have adequate testing in place; without adequate testing, you cannot have a differentiated strategy and that, to me, is where India can do much better than it has done so far.

One of the concerns that you have been expressing is what happens when we come out of it, to not just the people who are testing COVID positive, but for those who are suffering from so many other ailments, including ailments that may require urgent intervention like surgeries and so on.

This worries me so much because I work on tuberculosis (TB), and I know for a fact that a lot of people in India have simply not shown up on the TB notification registers in the last two months, just because they simply have not left their homes. They have not been able to seek care, and even if they seek care, there is nobody there to look after them: private establishments are closed; GPs [general practitioners] are gone; there is no testing in place. So if this is happening to TB, I cannot imagine it not happening to other diseases.

When the lockdowns ease this month, I predict a massive surge in the number of people who are going to be seeking [care] for all sorts of ailments that they have been just holding on. I am calling this the “big surge”. For example, diabetes could now be severe diabetes; hypertension could now be uncontrolled hypertension; mental health problems may have worsened. People may have had mild heart attacks they have ignored. So, you are going to have a flood of people seeking care. I know, for example, one of my own friends has had to delay cancer chemotherapy because they just could not go out. And if you delay cancer chemotherapy, that can have a bad impact on a person’s outcome. So, when this big surge happens, the public system will still be dealing with COVID, because COVID has not gone anywhere. It is continuing to climb every day and India will soon--in about 10 days or so--hit 100,000 cases. So COVID has not gone anywhere, the public system is clearly and fully focused on COVID. A lot of private establishments are shut. I am not sure if many of them will come back online quickly; some of them have been sealed because of COVID cases. GPs have to come back and even when they come back, they are not going to be at full capacity in the immediate period. So, my worry is between a public system that is fully focused on COVID and a private sector that is greatly weakened in its capacity--even the private system that is available may jack up their prices because they have lost revenues the last 60 days or so and they need to kind of “catchup”.

And then, when the disease spectrum shifts towards more severe TB, diabetes or cancer, you need a lot more tertiary care at that point. Tertiary care in the private sector, even without COVID, is a very expensive proposition. So, all of this, I worry, will hit the poorest people the hardest. I think the middle, the upper middle class, and the rich will find a way, eventually. But it is the poorest segment which would have more advanced disease, that would probably struggle the most; and unless there is a plan for them, I fear all-cause mortality of all conditions in India will go up. In fact, TB mortality is predicted to climb very high in the coming months. Malaria mortality is supposed to double actually in many settings.

Could you put some numbers to that? For instance, in TB, how many patients do you think are there who may not have been seen for about 2 months?

India reports around 2.7 million TB patients every year. But, in the last two months, the monthly notification has dropped by about 80%. That is a massive drop in notifications, and this is seen in both private and in public systems. That does not mean TB has disappeared. It just means people have not sought care, and if you do not seek care for TB, it will become worse in your lung and push you towards what we call smear positive and advanced cavitary disease, which means they are highly likely to transmit when they start seeking care. They already would have transmitted the infection within the household--because you are cooped up with TB and you have people in your home for two months, intra-household transmission would have gone up. 

Mathematical modelling studies have now come out showing that [for] TB, malaria and AIDS, just as examples, the mortality is substantially going to worsen because of COVID-related disruptions in the coming months. In fact, TB [control] is predicted to be set back by 5-8 years. We are supposed to end TB in India by 2025, according to the Prime Minister’s declaration. That is not going to happen, there is simply no chance that it is ever going to happen. Now we will be lucky if we can end TB by 2035, because that much more work will need to be done. Same thing for other diseases. 

I am particularly frustrated and unhappy that even basic immunisations have come to a grinding halt, which means we may have children with measles or diphtheria or pertussis in the coming years—diseases that we had come close to getting rid off for a long time, and that really is scary, because children cannot afford to not be vaccinated.

I was talking to a paediatrician just the day before from Mumbai, and he said that he would urge all parents to ensure that children got all primary vaccinations without fail at any cost, even while some other booster shots and things like that could wait.

Yes, but hopefully it is available. That is the problem. It is not that parents are unwilling. In India, the anti-vaccine movement is not what we are worried about. We are worried about services not being available close to them in their community, especially in rural areas where the ASHA [accredited social health activist] worker, or the village health nurse does not come with the vaccines, parents may not be able to access it.

We have in a way kicked the can down the road, and we have to pick it up again now, as we go into June 2020. So, what is the way out?

The way out is to massively ramp up the ability to test, trace, and isolate. You need a whole army of healthcare workers dedicated to that. If necessary, India should contract with the private health sector, because the private health sector is currently really not doing well. They do not have much to do. So, you have to leverage, and I am hoping that this will force the Indian government to do a better job of regulating the private health sector. 

For the longest time, India has just allowed the private health sector to mushroom and dominate, and yet not “serve the country”, so to speak. Private health sector in India serves the richest and those who can pay. Now is the chance for the government to say, “we are in a crisis, you are an Indian establishment, you have to contribute to the cause”. Not make them broke, not expect them to do anything for free, but pay them a fair wage or tariff for any services that they offer. That seems to be a quick way to build capacity.

As you said, there is going to be an avalanche that is going to descend on the entire health system. How do we even begin to counter that?

Again, I cannot imagine India having the capacity purely in the public health system. India’s weakness, and at the same time, potential strength right now is the private health sector. I mean 80% of India’s outpatient care is in the private health sector. But somehow, the relationship between the private and public has always been one of mistrust. There has never been a happy situation where the private sector feels like it is welcome and wanted and treated with respect; and the government somehow always thinks that the government health system is the only way to go. I find this discussion very polarising. In my own field of TB, I find it frustrating that huge numbers of TB patients are treated in the private health sector, but many of them do not even want to notify that they are treating TB to the government. 

The government needs to work harder to win the trust and work with them. Somehow, getting private and public--the all-hands-on-deck approach--is almost critical in this crisis, because no one sector can do this. The government’s job, I think, would be to regulate, to enforce certain policies and norms, and reimburse the private sector for what is a fair tariff for the service. You cannot expect the private sector to do it for nothing. 

So, you are saying that if we split the load more smartly between the public and the private--the private, in any case, controls the major part of health capacity--then we will not face the kind of problem we might otherwise.

Again, in the short run, in a crisis, this is the only realistic way to build healthcare capacity. But in the long run, why did India even end up in this extremely privatised health sector? Because no government in the history of India has ever invested in health. India’s health expenditure is one among the lowest in the world. In fact, there are many sub-Saharan African countries which spend more on health in terms of per-capita GDP. So, India is still skating at around 1.5% of the GDP invested in health, which is simply never ever going to be adequate, especially not in a crisis. 

But you cannot build public health capacity in the middle of a lockdown. You cannot build capacity in the public health system, right when a battle is raging. When a battle is raging, you want instantaneous reinforcements. And I think, the army that you can call upon is this large private health sector that can and should contribute in a crisis. Private health sector should also realise that they are not doing anything for free, but in a time of crisis they have an obligation to contribute. They simply cannot turn away patients. 

So right now in a crisis, we need to bring all hands on deck--public and private. That is the only way to survive this crisis. But in the long run, if India increased investment, to say even 2.5% of the GDP, that would be amazing. People like Amartya Sen, scholars have been wanting and asking for this for decades In India. No government has ever felt health to be a priority. And after this crisis, if politicians still do not think of health as a priority, I do not know what to tell them. I mean, it is like madness. This is a great example, where if you do not invest in health, your economy is going to get shot, in every country.

The same thing is happening in America. America is learning it does not have a universal health coverage system, and millions of people are falling from the cracks in this crisis. I think countries that have universal health coverage have, in general, weathered this storm better than either highly privatised countries, or countries that are heavily dependent on medical insurance, which only the rich and privileged can take. I think that should be the long-term lesson for India--investing in health is investing in economy, and the sooner our politicians understand this, the better it is going to be for all of us

You have studied and worked in other countries as well. How would you relate what we are going through--in a smaller way, I am imagining--with the Ebola crisis in West Africa, which at least for those regions had substantial impact, and therefore caused maybe the same set of problems and then responses?

There is simply nothing in human history that even comes close to what we are witnessing right now. I think what makes it very different from Ebola, for example, is that Ebola primarily affected poor African countries and it still does. The epidemic in DRC Congo is a good example. It is just that, this is one strange epidemic, which has hammered the highest income countries the hardest, which is the opposite of what most of us are used to in public health. We expect poor countries to perform poorly and be really devastated. But we are finding the world’s richest countries, even the US, absolutely on the mat right now. UK has lost the plot, Italy, France, Spain, Germany, you name it. Some of the biggest superpowers are absolutely struggling in this crisis. Except for countries like Australia and New Zealand that have done fairly well, most rich countries have struggled. 

And I worry that because they are struggling so much and taking devastating hits, I also worry what this pandemic will do to how rich countries will think about foreign aid, for example. I worry that many of them will cut back foreign aid to poor countries in the future. I worry that poorer countries, especially in sub Saharan Africa, will become more aid-dependent because they are also starting to see a lot of cases and their economies cannot withstand it. 

So, I worry about the world becoming more inequitable in the coming decades, because the rich countries will kind of contract into a nationalistic, isolationistic, protectionist framework and will not be willing to consider global solidarity. What we need now is global solidarity. But I worry it is everyone for himself or herself kind of an approach. Every country has retracted to protecting itself and I worry what this might mean for the next pandemic, if we cannot work together. Or what will happen to the climate crisis that is going to be a massive problem in the coming decades. Again, no one country can solve the climate crisis. Global solidarity is really under threat right now, and I would love to see countries more collaborative than competitive and isolationist.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Mumbai: India will be lucky if it ends tuberculosis by 2035--a decade later than targeted--says Madhukar Pai, Canada Research Chair in epidemiology and global health and director of the McGill International TB Centre in Montreal, Canada, pointing to an 80% drop in monthly notifications of TB because of COVID-19-related disruptions.

As India emerges from lockdown in phases, the healthcare system will see a “big surge” of patients such as those with more severe tuberculosis, uncontrolled hypertension and diabetes, and mild heart attacks that have been ignored due to COVID-19-related disruptions, says Pai, adding that the government needs to rope in India’s private health sector and pay them a fair tariff to overcome the crisis, Pai said.

While a differentiated lockdown strategy based on the spread of the disease is desirable, testing needs to be ramped up massively for this to be efficient, says Pai, who did his medical training and community medicine residency in Vellore, Tamil Nadu, and also did his PhD in epidemiology from the University of California in Berkeley.

Edited excerpts: 

It is a Hobson’s choice. We have to emerge from this lockdown, because, among other things, we have been in it for too long; and secondly, we know that we are going to be faced with some very difficult conditions and situations as we do, given the fact that the number of COVID-19 cases are rising even as we speak.

It is an incredibly tough choice, not just for India; every country is pretty much struggling with it. Take America for example. They are easing restrictions even as their cases continue to climb day after day. [It is the] same thing in my province in Canada, Quebec--cases continue to rise every day, and yet the province is planning to lift restrictions. When your cases are rising and you remove restrictions such as physical distancing, everybody is worried about the surge in cases again. We may have to go through multiple peaks and troughs before anything can really happen, because there is no vaccine on sight, in the immediate future--definitely not for this year. So, what do we then do?

For countries like India, the lockdown has been brutal, especially for the millions of people who live below the poverty line. If they do not work that day, they do not eat that day. So, I completely understand the importance of lifting restrictions. The WHO [World Health Organization] has listed six criteria that countries have to have in place before they can ease restrictions. India definitely does not meet many of the criteria, and yet India is going ahead. The same could apply for the US, for example, for that matter. For example, you need a lot of testing capacity, to be able to keep track of the virus. They talk about the package of “test, trace, and isolate”. That requires incredible capacity for a country of 1.3 billion people and India’s testing rates are very low right now, which means we simply do not know how widespread this epidemic is. We do not have serological surveys to know what proportion of Indians are already infected. 

I think what will work in India’s favour, and I hope this is true, is that the young population structure will somehow push the disease severity towards milder forms or asymptomatic forms, and I am hoping that would somehow carry us through. But India has to absolutely increase capacity for testing, tracing and isolating, handwashing, preventing large gatherings like movie theatres, stadiums. I think those are all common sense approaches that India absolutely can do.

And also, the differentiated strategy--which I am happy to see is already happening--that you do not have to lock down a place that is hardly reporting any cases. You focus your efforts more on those pockets where there is a lot of confirmation and find a way to intensely engage in that area. But that implies that you have adequate testing in place; without adequate testing, you cannot have a differentiated strategy and that, to me, is where India can do much better than it has done so far.

One of the concerns that you have been expressing is what happens when we come out of it, to not just the people who are testing COVID positive, but for those who are suffering from so many other ailments, including ailments that may require urgent intervention like surgeries and so on.

This worries me so much because I work on tuberculosis (TB), and I know for a fact that a lot of people in India have simply not shown up on the TB notification registers in the last two months, just because they simply have not left their homes. They have not been able to seek care, and even if they seek care, there is nobody there to look after them: private establishments are closed; GPs [general practitioners] are gone; there is no testing in place. So if this is happening to TB, I cannot imagine it not happening to other diseases.

When the lockdowns ease this month, I predict a massive surge in the number of people who are going to be seeking [care] for all sorts of ailments that they have been just holding on. I am calling this the “big surge”. For example, diabetes could now be severe diabetes; hypertension could now be uncontrolled hypertension; mental health problems may have worsened. People may have had mild heart attacks they have ignored. So, you are going to have a flood of people seeking care. I know, for example, one of my own friends has had to delay cancer chemotherapy because they just could not go out. And if you delay cancer chemotherapy, that can have a bad impact on a person’s outcome. So, when this big surge happens, the public system will still be dealing with COVID, because COVID has not gone anywhere. It is continuing to climb every day and India will soon--in about 10 days or so--hit 100,000 cases. So COVID has not gone anywhere, the public system is clearly and fully focused on COVID. A lot of private establishments are shut. I am not sure if many of them will come back online quickly; some of them have been sealed because of COVID cases. GPs have to come back and even when they come back, they are not going to be at full capacity in the immediate period. So, my worry is between a public system that is fully focused on COVID and a private sector that is greatly weakened in its capacity--even the private system that is available may jack up their prices because they have lost revenues the last 60 days or so and they need to kind of “catchup”.

And then, when the disease spectrum shifts towards more severe TB, diabetes or cancer, you need a lot more tertiary care at that point. Tertiary care in the private sector, even without COVID, is a very expensive proposition. So, all of this, I worry, will hit the poorest people the hardest. I think the middle, the upper middle class, and the rich will find a way, eventually. But it is the poorest segment which would have more advanced disease, that would probably struggle the most; and unless there is a plan for them, I fear all-cause mortality of all conditions in India will go up. In fact, TB mortality is predicted to climb very high in the coming months. Malaria mortality is supposed to double actually in many settings.

Could you put some numbers to that? For instance, in TB, how many patients do you think are there who may not have been seen for about 2 months?

India reports around 2.7 million TB patients every year. But, in the last two months, the monthly notification has dropped by about 80%. That is a massive drop in notifications, and this is seen in both private and in public systems. That does not mean TB has disappeared. It just means people have not sought care, and if you do not seek care for TB, it will become worse in your lung and push you towards what we call smear positive and advanced cavitary disease, which means they are highly likely to transmit when they start seeking care. They already would have transmitted the infection within the household--because you are cooped up with TB and you have people in your home for two months, intra-household transmission would have gone up. 

Mathematical modelling studies have now come out showing that [for] TB, malaria and AIDS, just as examples, the mortality is substantially going to worsen because of COVID-related disruptions in the coming months. In fact, TB [control] is predicted to be set back by 5-8 years. We are supposed to end TB in India by 2025, according to the Prime Minister’s declaration. That is not going to happen, there is simply no chance that it is ever going to happen. Now we will be lucky if we can end TB by 2035, because that much more work will need to be done. Same thing for other diseases. 

I am particularly frustrated and unhappy that even basic immunisations have come to a grinding halt, which means we may have children with measles or diphtheria or pertussis in the coming years—diseases that we had come close to getting rid off for a long time, and that really is scary, because children cannot afford to not be vaccinated.

I was talking to a paediatrician just the day before from Mumbai, and he said that he would urge all parents to ensure that children got all primary vaccinations without fail at any cost, even while some other booster shots and things like that could wait.

Yes, but hopefully it is available. That is the problem. It is not that parents are unwilling. In India, the anti-vaccine movement is not what we are worried about. We are worried about services not being available close to them in their community, especially in rural areas where the ASHA [accredited social health activist] worker, or the village health nurse does not come with the vaccines, parents may not be able to access it.

We have in a way kicked the can down the road, and we have to pick it up again now, as we go into June 2020. So, what is the way out?

The way out is to massively ramp up the ability to test, trace, and isolate. You need a whole army of healthcare workers dedicated to that. If necessary, India should contract with the private health sector, because the private health sector is currently really not doing well. They do not have much to do. So, you have to leverage, and I am hoping that this will force the Indian government to do a better job of regulating the private health sector. 

For the longest time, India has just allowed the private health sector to mushroom and dominate, and yet not “serve the country”, so to speak. Private health sector in India serves the richest and those who can pay. Now is the chance for the government to say, “we are in a crisis, you are an Indian establishment, you have to contribute to the cause”. Not make them broke, not expect them to do anything for free, but pay them a fair wage or tariff for any services that they offer. That seems to be a quick way to build capacity.

As you said, there is going to be an avalanche that is going to descend on the entire health system. How do we even begin to counter that?

Again, I cannot imagine India having the capacity purely in the public health system. India’s weakness, and at the same time, potential strength right now is the private health sector. I mean 80% of India’s outpatient care is in the private health sector. But somehow, the relationship between the private and public has always been one of mistrust. There has never been a happy situation where the private sector feels like it is welcome and wanted and treated with respect; and the government somehow always thinks that the government health system is the only way to go. I find this discussion very polarising. In my own field of TB, I find it frustrating that huge numbers of TB patients are treated in the private health sector, but many of them do not even want to notify that they are treating TB to the government. 

The government needs to work harder to win the trust and work with them. Somehow, getting private and public--the all-hands-on-deck approach--is almost critical in this crisis, because no one sector can do this. The government’s job, I think, would be to regulate, to enforce certain policies and norms, and reimburse the private sector for what is a fair tariff for the service. You cannot expect the private sector to do it for nothing. 

So, you are saying that if we split the load more smartly between the public and the private--the private, in any case, controls the major part of health capacity--then we will not face the kind of problem we might otherwise.

Again, in the short run, in a crisis, this is the only realistic way to build healthcare capacity. But in the long run, why did India even end up in this extremely privatised health sector? Because no government in the history of India has ever invested in health. India’s health expenditure is one among the lowest in the world. In fact, there are many sub-Saharan African countries which spend more on health in terms of per-capita GDP. So, India is still skating at around 1.5% of the GDP invested in health, which is simply never ever going to be adequate, especially not in a crisis. 

But you cannot build public health capacity in the middle of a lockdown. You cannot build capacity in the public health system, right when a battle is raging. When a battle is raging, you want instantaneous reinforcements. And I think, the army that you can call upon is this large private health sector that can and should contribute in a crisis. Private health sector should also realise that they are not doing anything for free, but in a time of crisis they have an obligation to contribute. They simply cannot turn away patients. 

So right now in a crisis, we need to bring all hands on deck--public and private. That is the only way to survive this crisis. But in the long run, if India increased investment, to say even 2.5% of the GDP, that would be amazing. People like Amartya Sen, scholars have been wanting and asking for this for decades In India. No government has ever felt health to be a priority. And after this crisis, if politicians still do not think of health as a priority, I do not know what to tell them. I mean, it is like madness. This is a great example, where if you do not invest in health, your economy is going to get shot, in every country.

The same thing is happening in America. America is learning it does not have a universal health coverage system, and millions of people are falling from the cracks in this crisis. I think countries that have universal health coverage have, in general, weathered this storm better than either highly privatised countries, or countries that are heavily dependent on medical insurance, which only the rich and privileged can take. I think that should be the long-term lesson for India--investing in health is investing in economy, and the sooner our politicians understand this, the better it is going to be for all of us

You have studied and worked in other countries as well. How would you relate what we are going through--in a smaller way, I am imagining--with the Ebola crisis in West Africa, which at least for those regions had substantial impact, and therefore caused maybe the same set of problems and then responses?

There is simply nothing in human history that even comes close to what we are witnessing right now. I think what makes it very different from Ebola, for example, is that Ebola primarily affected poor African countries and it still does. The epidemic in DRC Congo is a good example. It is just that, this is one strange epidemic, which has hammered the highest income countries the hardest, which is the opposite of what most of us are used to in public health. We expect poor countries to perform poorly and be really devastated. But we are finding the world’s richest countries, even the US, absolutely on the mat right now. UK has lost the plot, Italy, France, Spain, Germany, you name it. Some of the biggest superpowers are absolutely struggling in this crisis. Except for countries like Australia and New Zealand that have done fairly well, most rich countries have struggled. 

And I worry that because they are struggling so much and taking devastating hits, I also worry what this pandemic will do to how rich countries will think about foreign aid, for example. I worry that many of them will cut back foreign aid to poor countries in the future. I worry that poorer countries, especially in sub Saharan Africa, will become more aid-dependent because they are also starting to see a lot of cases and their economies cannot withstand it. 

So, I worry about the world becoming more inequitable in the coming decades, because the rich countries will kind of contract into a nationalistic, isolationistic, protectionist framework and will not be willing to consider global solidarity. What we need now is global solidarity. But I worry it is everyone for himself or herself kind of an approach. Every country has retracted to protecting itself and I worry what this might mean for the next pandemic, if we cannot work together. Or what will happen to the climate crisis that is going to be a massive problem in the coming decades. Again, no one country can solve the climate crisis. Global solidarity is really under threat right now, and I would love to see countries more collaborative than competitive and isolationist.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.


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