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“I looked down; my clothes hung formlessly on my shrunken limbs; the hand that lay on my knee was corded and hairy. I was once more Edward Hyde.” Robert Louis Stevenson in Dr. Jekyll and Mr. Hyde
In the queue
I was standing in the queue for a RT-PCR test to be done. I looked down and gazed at the round markings drawn on the floor. Were they really one meter apart? One could easily talk to the person ahead or behind in the queue. The person ahead of me was in a wheelchair with two attendants. The person behind me was a middle aged lady busy on her mobile.
“Look at the brighter side! It can be killed by ordinary soap!” She was telling someone. She found me turning and looking at her. Through her specs, I could see that her eyes quickly crinkled into a ‘Duchenne smile.'1 She was trying to be socially polite. Her lower face was covered in a large yellow ill fitting mask.
I tried to smile back. Inside, I was worried about her ill-fitting mask and constant talking. Was I being exposed to an additional dose of SARS-COV-2? I had come for a test as one of my colleagues had tested positive for COVID-19. I had two sessions of coffee with him during the last two days before he tested positive. The only time one takes off one’s mask in the workplace is while having coffee.
I turned away from her but could still hear her yakking on her phone, “Look, how much benefit this virus has given us! The air has become cleaner, road accidents have stopped and you can now hear the birds sing. People have also stopped spending on unnecessary things!”
Another positive-thinking freak! I was judging her in my thoughts. She went on regardless,“ It is as if it’s Kalki, the final avatar of Vishnu, who has come to teach us how to live! So cheer up son! Take it in the right spirit. Unfortunately, this too shall pass.” and then she laughed loudly.
After a few minutes of such spirited optimism, her conversation was abruptly cut off from the other side. I could hear the male voice at the other end even with that mandatory one meter distance. The caller on the phone was saying,”Okay stop, I am not a child anymore. I need to go back to my work. Bye!”
There was silence after that, followed by just a few faint sniffles. I turned back to see that the optimistic lady was wiping her tears. I realised that I had misjudged a mother.
I went in for my test and presented my receipt to three aliens in a small room. One of them scraped my nasopharynx and asked me to go out. When I came out, I was surprised to see that optimistic lady wave at me. As I passed her, she said,”I have worked with you long back! I recognised your face when you took off your mask for the test.” I was horrified as she went on to uncover her face, hoping that I would recognise her immediately. “AB! I was AM then!” She announced her present and her maiden name.
I found it very awkward. My memory isn’t what it used to be. I just could not place her but said, “Well, I do remember your face, but I cannot recollect where we worked together? Are you a physician?”
She tried to remind me, “I think it was Pune. I was in the Army then. The Station Health Organisation!”
Then it came rushing back. It was during the pandemic of H1N1 influenza (Swine flu). I was commanding the hospital associated with Armed Forces Medical College, while she was providing the community health cover to the station. Back then, she had proven very innovative in educating people about the precautions to be taken during the epidemic.
She looked different. Obviously, age and maturity had added grace to her appearance. I learnt that she was now working with an NGO doing similar work in a tribal area. She had travelled to this city as her father had developed COVID-19.
Dormant and latent infections
I also remembered that she used to be very knowledgeable. We had had a discussion on hepatitis B virus infection after she had come across one of my papers on the subject.2 She had raised a lot of intriguing questions.
That discussion was about our microbiome (collective name for the trillions of bacteria and other organisms that we carry in and on ourselves)3 and the pathogens that infect us. She knew that most of the research had focussed on bacteria, archaea or fungi and very little was known about viruses.
She had asked me back then, “Why is it that we are considered normal when we carry dormant pathogens such as Mycobacterium tuberculosis,4 but are considered to have an ‘infection’ if we carry hepatitis B virus.”5 Before I could even attempt an answer, she had fired another question, “Why is it that we are okay if the Varicella zoster is hiding inside us,6,7 but definitely not okay if it is another virus – the Human immunodeficiency virus?8
I had found it difficult to come up with a convincing answer immediately then. Presently I asked her, “Were you talking to your son sometime back?”
She looked sharply at me and then said in a low voice, “No, it was one of my young health workers. He is depressed because all his life’s plans have been upset by COVID-19 pandemic. I was trying to cheer him up.”
Now I realised that I had wrongly judged a woman with a big heart. Overtly, I said. “I agree, SARS-COV-2 has changed a lot of things.”
“Tell me sir, should it really? After all it is just one virus, like billions others!” She was back to asking questions.
“Ma’am, a virus is like a piece of information. And you know different types of information or news can affect us differently.” I tried to generalise.
“How is it ‘just a piece of information’? Isn’t it a micro-organism?” She asked
“Why is that?” came a prompt counter-question.
“In molecular terms, virus is a ‘gift-wrapped’ nucleic acid. The gift-wrapping is virtually always a virus-encoded protein coat or capsid which may or may not include a lipid coat from the host. It is the gift wrapping that attracts us to it. As such, the virus has no metabolic processes of its own and remains dead in an inanimate surrounding.11 It comes alive only when it touches a suitable living cell.”12
“How can a living cell breathe life into a dead molecule?” She asked. For a second, I made the mistake of thinking that she had forgotten her basic virology. I tried to simplify the answer.“Because its outer coat (gift wrap) contains chemical keys to open the passage into a living cell. Once inside, it hijacks the life processes inside the living cell to make copies of itself!”
I think she already knew well, as she replied “Like SARS-COV-2 enters through ACE-2 receptors on the cells of the throat, lungs and intestines!”13,14 As I nodded she threw her question again at me, “Why do you call it a piece of information?”
I replied as I would to a student.“I am sure you know that the bacteria keep sharing their gossip (information) about antibiotic resistance through their own ‘Whatsapp chats’, through the bacteriophages, which are actually viruses for bacteria. And nucleic acids can be considered as nature’s ‘pen drives’ that can be duplicated wherever or whenever required. Nature uses nucleic acids to carry information.”
“So, as per you, SARS-COV-2 is just a piece of bad news?” She asked.
“Good news or bad depends on our perspective. You were just telling how good it has been to humanity in general.” I said.
She was called in for her test at this point. She went into the testing room saying, “You don’t agree? Let me finish my tests and I will come to your office for a few more queries.” As she went in, I turned towards my own room, pondering over where I stood on this subject. I felt COVID-19 had been agonising for the most.
SARS-COV-2 had caused an unprecedented pandemic. About 5% of patients went on to become critically ill requiring ICU care.15,16,17, and many of these also had associated comorbidities.18 The Indian Government sources placed national recovery rate at around 77% and the case fatality rate to be 1·8%.19
She came back and peeped into my room and started off where she had left. “Your demeanour told me that you don’t believe in the positive impact of COVID-19?”
“I have read somewhere that its effect on the environment ultimately may not be as good as you think.”20,21 I reluctantly replied, “Also look at it’s indirect effect! Nationwide lockdown imposed by the Central government in March was appreciated by the WHO,22,23 but has had a negative effect on people’s livelihood in India. Similar adverse effects have been noted elsewhere too but it seems to have broken the back of Indian economy.”24
She chirped, “Lockdown did flatten the curve!”
Impact of COVID-19
I commented, “Lockdown created a parallel crisis for many people as incomes fell dramatically. 25 There was panic among the public. Lack of local support for labourers led to their widespread migration, which was one reason for rapid spread of this infection. Many businesses collapsed and industries were brought to their knees.”
She was still defiant, “Why blame the virus for our social woes? If industrialists would have agreed to feed people who bring them the profit, all this would not have happened ”
“Lets look closer home. We have spent the last five decades or so developing robust research methodology. We now swear by ‘evidence based medicine.’ For every guideline and recommendation, we made it mandatory to write ‘grade of evidence’26 at its end to show the strength of evidence on which the recommendation was based. But when it came to COVID-19, all was forgotten. We lost all the scientific gains in one stroke!”
“Why do you say so?” She asked.
“The prime minister of the country had advised the journalists to avoid spreading pessimism, negativity and rumours in media reporting.27 It seems the professional scientific organisations in India have taken this advice too seriously. The Indian Council of Medical Research (ICMR), the watchdog of all research and ethics in our country started straying from scientific evidence, appearing at worst politically motivated and at best overly optimistic.28
She just smiled and said, “Why do you blame the virus for it?”
Science or sycophancy
“Director General, ICMR, announced that it envisaged launching a coronavirus vaccine by Aug 15.29 Everyone knows it would have been impossible without flouting all safety regulations.” I said.
“It was possibly rhetoric to boost the morale of lay public.” She chipped in.
I went on “ICMR recommended prophylactic treatment with hydroxychloroquine without any sound scientific basis.”30 There were also reports that it had asked researchers to hush up COVID-19 prevalence information from the hotspots they had included in their scientific papers as evidence.”31 ICMR is now infamous for going against scientific wisdom.32
“How can you blame the virus for it?” She was still defending her point of view,”Our country has very poor facilities. And people panic easily. They possibly did all this to reassure people!”
I disagreed with her, “It is not the job of ICMR to reassure people and the people of this country need much more than mere reassurance from those in power. Medical care of patients who developed severe illness during this pandemic has been chaotic. Many hospitals were not accepting patients.33,[ref]https://www.thehindu.com/news/national/other-states/staff-crunch-forces-aiims-bhubaneswar-to-shut-opd-service/article32033084.ece[/ref],34 Some were overflowing while others were empty.35,36 Many private hospitals have closed down.37,38 It all had a snowballing effect on people’s agony.”
She now said in a sharp voice, “I feel that Indians doctors do not have the gall and the spine to stand up to dubious administrative decisions.”
I replied. “This is not an Indian problem alone. Look at Russia,39 or at WHO.40 Even in the USA, it seems, the crisis has been converted into a tragedy.41 Look at the US FDA, one of the most respected organisations that arose from the ashes of the Thalidomide disaster. It is famous for pledging to provide accurate and science-based information. Look at what this FDA has done!”42,43
“What has the FDA done?”She asked.
Science or politics
“A similar story. Immediately after President Trump widely and aggressively promoted hydroxychloroquine as a ‘miracle drug,’ (March 30, 2020), the FDA granted an Emergency Use Authorization (EUA) for this drug without any sufficient or meaningful supportive evidence. It had to be revoked soon thereafter.”44 I elaborated.
“Okaayyeee.” She was patiently listening.
“ FDA Commissioner Hahn publicly also hurriedly announced in a press conference the effectiveness of plasma exchange as treatment. He mentioned that it reduced mortality by 35%, based on a preprint version of a non-peer reviewed paper.45 The results were later refuted by other studies including an Indian study.46,47
“What else?” She asked
“FDA granted emergency use authorization to broaden the remdesivir use to include any patient hospitalized with moderate COVID-19, without sufficient evidence. Moreover, FDA also expressed willingness to authorize a vaccine before Phase 3 trials were complete.”48
She gave a surprised look, “But why do you blame the SARS-COV-2 virus for these human blemishes? One can debate whether the evidence threshold need to be downgraded in the face of global emergency. ”
I replied,“Consider a recent report of transverse myelitis seen in a volunteer being tested for a COVID-19 candidate vaccine.49 The person was left paralysed with an uncertain future – just because he volunteered to be a participant in a vaccine trial. Some other vaccines have also reportedly caused similar complications. It led to the halting of trials pending reevaluation of the situation.”50,51 I added.
“So, you do not believe that the evidence threshold should change in the face of global emergency. I agree with you. It is normal healthy population that will be vaccinated.” She remained unruffled, “You are basically saying that the ugly side of medical science or its promoters has been uncovered by COVID-19 pandemic. Again, can you blame the virus for their behaviour?”
I retorted, “People already feel that vaccine approval is being driven by political pressure. If an effective vaccine does come, its acceptability may not be what is desired!”52
“Yes, a trust deficit will be a big disaster.” She remarked.
She finally accepted, “Our desire to seek hope amid desperation can lead to iniquitous action by many, whether scientist or not, with significant loss of credibility.”58
Is this evidence based?
I replied, “Today, most hospitals are using treatments like remdesivir, favipiravir, tocilizumab and plasma therapy, which have been officially approved. They cost a lot of money, and do have adverse effects. None of these drugs have been proven to save lives with any degree of certainty. While patients are demanding these treatments in the face of an uncertain future today, tomorrow they may just turn around and blame the doctors for giving it without proven benefit!”
“I agree, the health of individual patients and the public at large will be best served by remaining true to our time-tested approach to clinical trial evidence and drug evaluation, rather than cutting corners and resorting to appealing, yet risky, quick fixes.”59 She had relented
I paused for a moment and added, “And we still are not sure whether SARS-COV-2 is a man-made disaster60 or another one of nature’s tricks to keep the balance.”
She remarked,“I have noticed that you have been focussing too much on the negative news”
I thought for a minute. “Ma’am, we are talking about one of the most lethal pandemics in the history of mankind. What can be positive about it?”
“Oh the world is full of miracles! Can’t you see that innumerable medical, nursing and allied professionals have risen to the occasion to provide superhuman service to the ill within this skewed system?”
“Yes, I am aware.” I agreed.
“Haven’t you heard of brave-hearts who came out in the thick of the pandemic to help poor people get to their homes, despite the risk of infection to themselves?”61
I just nodded. I was proud of them.
“Hasn’t it given us an opportunity to review several of our collective decisions!” She asked.
“What decisions? I don’t get your point.” I confessed.
“We have seen that a threat to health has the capability of grounding the economy of our vast country. Should we be satisfied in keeping the health budget as low as around 1% of GDP?62 Should we ignore healthcare workers when it comes to giving respect63 and remunerations as we have been doing so far?” She asked.
“That has been a demand by every professional body!” I said
“Don’t you think our planners will now get this point. A lesson learnt the hard way?” She commented.
I was doubtful, “In India, health related decisions are generally taken by non-medical administrators!”
She sounded very hopeful. “India can learn from Taiwan.”
Lessons for us
I raised my eyebrows and looked at her.”Taiwan?”
She said, “Taiwan’s main weapon against COVID-19 has been its vice president – an epidemiologist, who orchestrated the whole response.64 Having experienced SARS about 17 years back, Taiwan was already prepared for the threat of an emerging infectious disease. As early as December 31, 2019, Taiwan had begun implementing onboard quarantine of direct flights from Wuhan on the very same day that China had reported this disease.”
She continued, “On January 2, 2020, Taiwan established a response team for the disease and activated the Central Epidemic Command Center (CECC). The CECC was empowered to effectively integrate resources from various ministries and invest itself fully in the containment of the epidemic. We woke up much later.”
“As of July 19, 2020, Taiwan had only 455 confirmed cases with seven deaths.65,66 The statistics continue to show that Taiwan’s aggressive efforts to control the epidemic are working.67,68 There is a lot to learn from this country about health management.”
I responded, “Will this message ever reach the person who matters?”
She got up to go,”Sir, I can say only one thing about SARS-COV-2. It is just trying to survive! All untoward effects you see are man made.”
I too stood up, “Why do you say that?”
The enemy within
As she walked to the door, she added,”The clinical illness you see in humans is caused by their own immune system at the molecular level. And all the other undesirable things you mentioned are related to man’s fear or ambition at the gross level.”
She was right. It is well known that the man is his worst enemy.69,70 Agreed, all that is vile and immoral is within us. So is all the benevolence and humanitariasm. Unfortunately, the number of people killed by natural disasters is overshadowed by those killed by mankind with his deliberate actions; may it be in the name of religion, in the name of equality; in the name of protection of territory or in the interest of somebody.
COVID-19 is an opportunity to strengthen our Dr Jekyll against Mr Hyde. And for us in India, it is the most auspicious time of the year to let our Ram root out the Ravan within us.
|↑1||Girard JM, Shandar G, Liu Z, Cohn JF, Yin L, Morency LP. Reconsidering the Duchenne Smile: Indicator of Positive Emotion or Artifact of Smile Intensity? Int Conf Affect Comput Intell Interact Workshops. 2019 Sep;2019:594-599. doi: 10.1109/acii.2019.8925535.|
|↑2||Anand AC. A virus questions human definitions of health. Natl Med J India 1998; 11(6): 290-91. Available at http://archive.nmji.in/archives/Volume-11/issue-6/speaking-for-myself.pdf|
|↑3||Behrouzi A, Nafari AH, Siadat SD. The significance of microbiome in personalized medicine. Clin Transl Med. 2019;8(1):16. Published 2019 May 13. doi:10.1186/s40169-019-0232-y|
|↑4||Lipworth S, Hammond RJ, Baron VO, Hu Y, Coates A, Gillespie SH. Defining dormancy in mycobacterial disease. Tuberculosis (Edinb). 2016 Jul;99:131-42. doi: 10.1016/j.tube.2016.05.006. Epub 2016 May 28. PMID: 27450015.|
|↑5||Sharma SK, Saini N, Chawla Y. Hepatitis B virus: inactive carriers. Virol J. 2005;2:82. Published 2005 Sep 28. doi:10.1186/1743-422X-2-82|
|↑7||Daniel P. Depledge et al. A spliced latency-associated VZV transcript maps antisense to the viral transactivator gene 61, Nature Communications (2018). DOI: 10.1038/s41467-018-03569-2|
|↑8||Amy E. Baxter, Julia Niessl, Rémi Fromentin, Jonathan Richard, Filippos Porichis, Roxanne Charlebois, Marta Massanella, Nathalie Brassard, Nirmin Alsahafi, Gloria-Gabrielle Delgado, Jean-Pierre Routy, Bruce D. Walker, Andrés Finzi, Nicolas Chomont, Daniel E. Kaufmann. Single-Cell Characterization of Viral Translation-Competent Reservoirs in HIV-Infected Individuals. Cell Host & Microbe, 2016; 20 (3): 368 DOI: 10.1016/j.chom.2016.07.015|
|↑13||Asghari A, Naseri M, Safari H, Saboory E, Parsamanesh N. The Novel Insight of SARS-CoV-2 Molecular Biology and Pathogenesis and Therapeutic Options. DNA Cell Biol. 2020 Jul 21. doi: 10.1089/dna.2020.5703. Epub ahead of print. PMID: 32716648.|
|↑15||Sharma R, Daga MK, Mawari G, Karra VK, Kumar N, Jha MK, et al. Global trends of clinical presentation of COVID-19. Indian J Med Spec 2020;11:59-64.|
|↑16||Srivastava N, Baxi P, Ratho RK, Saxena SK. Global Trends in Epidemiology of Coronavirus Disease 2019 (COVID-19). Coronavirus Disease 2019 (COVID-19). 2020;9-21. Published 2020 Apr 30. doi:10.1007/978-981-15-4814-7_2|
|↑17||Manabe T, Akatsu H, Kotani K, Kudo K. Trends in clinical features of novel coronavirus disease (COVID-19): A systematic review and meta-analysis of studies published from December 2019 to February 2020. Respir Investig. 2020;58(5):409-418. doi:10.1016/j.resinv.2020.05.005|
|↑19||Chatterjee P. Is India missing COVID-19 deaths? Lancet 2020; 396: 657. https://doi.org/10.1016/S0140-6736(20)31857-2|
|↑26||Kavanagh BP. The GRADE system for rating clinical guidelines. PLoS Med. 2009;6(9):e1000094. doi:10.1371/journal.pmed.1000094|
|↑28||Anonymous. COVID-19 in India: the dangers of false optimism (editorial). The Lancet 2020; 396: 867|
|↑41||Editors. Dying in a leadership vacuum. N Engl J Med2020;383:1479-80. doi:10.1056/NEJMe2029812 pmid:33027574|
|↑43||Tanne JH. Covid 19: NEJM and former CDC director launch stinging attacks on US response. BMJ 2020;371:m3925 http://dx.doi.org/10.1136/bmj.m3925|
|↑52||Avorn J, Kesselheim AS. Up Is Down – Pharmaceutical Industry Caution vs. Federal Acceleration of Covid-19 Vaccine Approval. N Engl J Med. 2020 Sep 15. doi: 10.1056/NEJMp2029479. Epub ahead of print. PMID: 32931162.|
|↑55||Cohen D, Carter P. WHO and the pandemic flu ‘conspiracies’. Br Med J 2010;340: c2912.|
|↑56||Evans MR. The swine flu scam? J Public Health (Oxf). 2010 Sep;32(3):296-7. doi: 10.1093/pubmed/fdq059. Epub 2010 Aug 4. PMID: 20685896.|
|↑58||Baden LR, Solomon CG, Greene MF, D’Agostino RB, Harrington D. The FDA and the Importance of Trust. N Engl J Med. 2020 Sep 30. doi: 10.1056/NEJMe2030687. Epub ahead of print. PMID: 32997901.|
|↑59||Rome BN, Avorn J. Drug Evaluation during the Covid-19 Pandemic. N Engl J Med. 2020 Jun 11;382(24):2282-2284. doi: 10.1056/NEJMp2009457. Epub 2020 Apr 14. PMID: 32289216.|
|↑62||https://data.worldbank.org/indicator/SH.XPD.GHED.GD.ZS[ref] Should we ignore healthcare workers when it comes to giving respect[ref]Ghosh K. Violence against doctors: A wake-up call. Indian J Med Res. 2018;148(2):130-133. doi:10.4103/ijmr.IJMR_1299_17|
|↑63||Ghosh K. Violence against doctors: A wake-up call. Indian J Med Res. 2018;148(2):130-133. doi:10.4103/ijmr.IJMR_1299_17|
|↑66||“CECC confirms 1 more COVID-19 case; male case returns to Taiwan from Hong Kong”, Taiwan Centers for Disease Control (TCDC), July 19, 2020. Also see TCDC Homepage, July 20, 2020.|
|↑70||Berglas S. Your Own Worst Enemy: Understanding The Paradox Of Self-defeating Behavior.1993. Available at https://www.amazon.com/Your-Worst-Enemy-Understanding-Self-defeating/dp/0465076807|
|↑71||Sketch modified from https://www.santabanta.com/photos/goddess-durga/9103045.htm?high=6|