A painting showing a cross section through SARS-CoV-2 surrounded by blood plasma, with neutralising antibodies in bright yellow. Illustration: David S. Goodsell, RCSB Protein Data Bank and Springer Nature; doi: 10.2210/rcsb_pdb/goodsell-gallery-025
On this day, last year, I pondered the empty streets fringed with tarpaulined handcarts and their dejected vendors discussing methods for survival. Then, the coronavirus was a monster to be trapped, masks were bijou couture, chemists were running out of sanitisers, hydroxychloroquine and pulse oximeters. Neighbours had oxygen cylinders stashed beneath their beds and doused their vegetables in bleach.
Today, I ponder the same empty streets, the same tarpaulined handcarts and those same dejected vendors. The coronavirus is on the prowl, masks are mandatory, neighbours are still mesmerised by their oximeters. A minuscule fraction of the nation is vaccinated. But for this difference, nothing has changed. The pulse is one of panic, accelerated each day with shrieks of new iterations of SARS-CoV-2. Actually, it is scarcely ever called that anymore. We talk of mutants and variants. This, we tell ourselves, is the second wave of COVID. Or is it the third?
Déjà vu. We have dedicated ourselves to the stupidities of 2020 again. What has living a year with SARS-CoV-2 taught us?
Besides its jargon, nothing.
Yet, we should be well-armed in information by now. What gets in the way? Panic.
Panic kills more efficiently than any virus can.
When the dust settles, if our species is still around, the damage caused by our panic will have a recognisable signature. As yet, we only see it in pixels.
To anyone following the pandemic as it unfolded, it was evident last year that severe COVID-19 was the result of an uncontrolled, uncontrollable, inflammatory response, the fallout of immunity gone wrong.
It was therefore likely to be more severe, even fatal, in people who had illnesses that enhanced inflammation. Think diabetes, think cardiovascular disease. And do think, please, because it is the root cause – do think obesity. It was also likely to be more severe in the elderly where inflammatory response is trigger-happy. We knew all this as early as March 2020.
It was self-evident. COVID-19 wasn’t just about the virus. It was about our body’s response to it. As the first response of innate immunity was subverted by the virus, the subsequent cascade of responses turned chaotic. And though it began in the upper respiratory tract, COVID-19 affected every body organ.
This virus engages with a receptor that is present in all body tissues. Its effect depends on how stable our immune response is. The target tissue for maximum injury is the inner lining of blood vessels – everywhere. This explains the mayhem in severe disease where not a single body function escapes disruption.
Unfortunately, immunity is nothing like what the Wellness Bazaar would have us believe. It cannot be ‘boosted’ by various molecules, compounds, exotic seeds, weeds and unidentifiable matter – vegetable, algal, fungal – no matter how earnestly endorsed by celebs. Even ancestral authority must be challenged. By now the nation has swallowed tons of turmeric boiled in the milk of contented cows, and it hasn’t helped. Nor will any other dependable from the kitchen shelf.
That’s usually countered with: Why not swallow them anyway? Even if they don’t help, they can’t possibly do any harm!
Yes, they can.
Those of us who are involved in the pharmacology of foods and spices are alternately thrilled and appalled by their chemistry. In the present situation, suffice it to say they contain molecules that influence the tightly regulated processes of inflammation and blood clotting. Not something you want to meddle with when facing SARS-CoV-2.
The only way to safeguard your immune process is to medically address any illness you may harbour – and otherwise live as sensibly as you can with plenty of fresh air and exercise, hearty delicious meals and a good night’s rest. I could, if you insist, validate that in biochemical terms. Every week there is a bit of research to tell us that, yes, common sense is good science too.
Common sense, alas, robs the moment of drama. To doctor and patient alike, this is very disappointing. The panic is mutual, and is always addressed by a prescription. This is a knee-jerk response. Every patient who tests COVID positive, or has been in contact with a case, is given a list of drugs, advised to keep an eye trained on the pulse oximeter and rush to hospital the moment O2 veers close to suspicious. The drugs are predictably, and provenly, useless. The standard prescription has an antibiotic, an antiviral, anti-parasitics old and new, a slew of vitamins and trace minerals, and enough Vitamin D to help you survive on the far side of the moon. Steroids are reserved for follow-up.
Let me name the beasts: hydroxychloroquine, ivermectin, favipiravir, doxycycline, zidovudine (AZT). They have all been tried, tested and found lacking.
Reason enough not to prescribe.
But today even an asymptomatic ‘positive’ is slammed with the lot. Even the prescription is redundant. These drugs are urged by family and friends.
There is no lack of information here, just a breakdown of trust between doctor and patient. The doctor doesn’t trust the patient’s intelligence, and vice versa. As a result, the first principle of medical care ‘do no harm’ is ignored.
That experience can be anything from caring to hellishly callous. It is the luck of the draw. Whichever, it is based on protocol. Decisions around the protocol must be made by the point-of-care physician who is young, inexperienced, and too often, unqualified. Any innate intelligence is rapidly subdued by the need to conform – to the protocol, to the system, to the job.
Hospitalisation further emphasises those inequalities that dictate every step of medical care. Beds, tests, imaging, drugs, oxygen and intensive care are available only if you can afford them.
If we are faced with COVID-19 of the severity experienced by the West, most Indians will be forced to go without medical care. Before it gets that bad, we need to decentralise and zone medical care in manageable units with maximum self-sufficiency. Indians show a remarkable capacity to organise in an emergency. Such self-sufficiency will also assure greater compassion and understanding, which is the first step towards a stable society.
Challenged by a ubiquitous illness with no therapy, we have done some dramatic, wonderful and dazzling science – we’ve produced vaccines. What response should the vaccine produce in us? Adequate neutralising antibodies and an appropriate T-cell response – which translates into less severe disease. Or no disease. This is the anticipated response – the rest is up to you. When it comes to COVID-19, the magic molecule is still, and forever, you. The vaccine is only as good as your response.
We have been unable to quell the pandemic because our approach has been weighted on the virus.
Why, that’s the nature of the beast, and you can’t stop that.
This virus was, from its very first manifestation, ubiquitous. Boundaries as shown on interactive maps were projections of presumed knowledge only. While working on my book last year, I came up with instance after instance of the virus asserting itself long before and far away from the Wuhan wet market event. Some of those observations are grudgingly admitted today.
Even more to the point, the WHO fact-finding report has validated the possibility of industrialised slaughter as a likely spillover event.
SARS-CoV-2 is a respiratory virus and the killing field is the lower airway.
Our first endeavour should be to protect this delicate part of the body. This virus latches onto the upper airway, and we have a beautiful defence system in place to keep it from getting to the lower reaches of the respiratory tract. We should ensure its health by keeping irritants to a minimum.
This means clean air. India has the most dismal story on that, and it is urgent that we clean up. This means calling a halt to construction projects, closing unregulated factories, cutting vehicle emissions – all measures that cripple capitalism. Lockdowns only worsen the situation for the poor by denying ventilation, by forcing people to huddle in small spaces full of cooking fumes. We cannot pattern our strategy on countries that have lifestyles far removed from ours.
The only thing that has worked universally is physical distancing. Vaccines are still a hope to hold on to. Yes, we’re running short, but that’s a temporary setback.
Meanwhile there is a lot we can do. Cut down respiratory irritants in our vicinity. Stop smoking. Get rid of incense sticks, sambrani and other fumigations, including mosquito coils.
Do not inhale steam: the defenders of the airway, cilia, are delicate structures that work efficiently only at body temperature.
Do not self medicate.
Do walk, run, dance. Sing, because it opens your lungs as much as your heart, but make certain your audience is at least six feet away.
And when all else disappoints, there is still cricket.
Surgeons Kalpana Swaminathan and Ishrat Syed write together as Kalpish Ratna. Their book, A Crown of Thorns: The Coronavirus & Us, was published in August 2020. A Pandemonium in Pakshila is due later this year.