Patricia Mukhim
There is a huge debate currently going on between the radical right and liberal left in Meghalaya. And I am talking here not of political partisan stances but the ideological one. The former wants the Government to come clean with names of all who have tested Covid+ive for one reason alone – so that each one of us knows if we have contacted a primary or secondary contact and can go for voluntary testing. The latter, however, feel that the need to know violates medical ethics and leads to stigmatisation of the Covid+ive person who may not be responsible for how he/she got the infection. The majority of us, as usual, swing between the two poles. If those tested positive are our kith and kin we would not want the world to know of it. Reason? We are by nature a secretive society. The patient detected with cancer would prevaricate and obfuscate rather than just say, “I was tested and found to have cancer of the …… (whatever). The family members too would get the signs and pretty much do the same thing until it becomes the gossip of the town. The point about cancer is, it’s not infectious and we can all mind our own businesses and shut up. Not so with Covid! This virus is a puzzle and keeps us flummoxed every single day.
Media reports of hospitals stigmatising people of ‘shnongs’ where certain areas are cordoned off as containment zones should be taken seriously. Those hospitals should be stripped of their licenses. After all, hospitals are there to provide health care. If health workers are themselves so paranoid then why blame the general public? This is where the publication of names becomes even more necessary because that would address the evil of assumption. Imagine a hospital assuming that every person in Umpling is Covid infected merely because large numbers of BSF personnel residing in a camp in that locality are infected! This is ridiculous!
A short but crisp write-up by Dr Bhaskar Ganguly circulating on social media, says that the medical and scientific world know much more about Covid now than they did in February, 2020 and that conservative treatment with drugs like Remdesivir and Favipiravir have reduced the patient’s own immune system from responding in an exaggerated manner resulting in Cytokine Storm. A Cytokine Storm is an over-production of immune cells and their activating compounds (cytokines), which, in a flu infection, is often associated with a surge of activated immune cells into the lungs. The resulting lung inflammation and fluid build-up can lead to respiratory distress and can be contaminated by a secondary bacterial pneumonia – often enhancing the mortality in patients.
This little-understood phenomenon is thought to occur in at least several types of infections and auto-immune conditions, but appears to be particularly relevant in outbreaks of new flu variants. Cytokine storm is now seen as a likely major cause of mortality in past pandemics – the 1918-20 “Spanish flu,” which killed more than 50 million people worldwide — and the H1N1 “swine flu” and H5N1 “bird flu” of recent years and now Covid (Source: The Scripps Research Institute, US). This stormy immune response not only kills the virus but the patient as well.
Then we come to another drug Dexamethasone. Reports from the National Institute of Health Research UK and the University of Oxford publication (June 16, 2020) says a total of 2104 patients were randomised to receive dexamethasone 6 mg once per day either by mouth or by intravenous injection) for ten days and were compared with 4321 patients randomised to usual care alone. Among the patients who received usual care alone, 28-day mortality was highest in those who required ventilation (41%), intermediate in those patients who required oxygen only (25%), and lowest among those who did not require any respiratory intervention (13%).
Dexamethasone reduced deaths by one-third in ventilated patients and by one fifth in other patients receiving oxygen only. There was no benefit among those patients who did not require respiratory support. Based on these results, one death would be prevented by treatment of around 8 ventilated patients or around 25 patients requiring oxygen alone. Given the public health importance of these results, the researchers are now working to publish the full details as soon as possible.
Peter Horby, Professor of Emerging Infectious Diseases in the Nuffield Department of Medicine, University of Oxford, and one of the Chief Investigators for the trial, said, ‘Dexamethasone is the first drug to be shown to improve survival in Covid-19. This is an extremely welcome result. The survival benefit is clear and large in those patients who are sick enough to require oxygen treatment, so Dexamethasone should now become standard of care in these patients. Dexamethasone is inexpensive, on the shelf, and can be used immediately to save lives worldwide.’
The challenge with Covid-19 is that seven months after its appearance, scientists are yet to arrive at a conclusion on the source of the virus, how the disease is transmitted, why some cases are more severe than others and whether people who have recovered from Covid-19 can get it again. Even in the mode of transmission scientists and doctors are learning new things every day. The WHO recently updated its brief on “Modes of transmission of virus causing Covid-19” and formally acknowledged “evidence emerging” of the airborne spread of the virus. In the brief, the WHO has formally acknowledged the possibility that the Covid-19 virus can remain in the air in crowded indoor spaces, where “short-range aerosol transmission, cannot be ruled out”. However, the WHO still maintains that transmission through respiratory droplets — when an infected person coughs, sneezes, talks, or sings — is still the primary mode of transmission of the virus.
WHO also mentions another type of transmission called fomite transmission where the virus is transmitted through infected surfaces — such as doorknobs, elevator buttons, handrails, phones, switches, pens, keyboards and, if not disinfected, even a doctor’s stethoscope.
Researchers across the world are also studying whether antibodies developed by the body in response to the virus can provide permanent immunity. Hence plasma therapy is gaining ground in the neighbouring state of Assam and Delhi as a possible cure. A new study by King’s College, London has found that those recovering from Covid-19 may have antibodies for only a few months. Upon analyzing the immune response of more than 90 people, the researchers found that antibody levels peaked about three weeks after the onset of symptoms and then started declining. Hence that’s the window period when the plasma ought to be donated. Quite a few have recovered after being given plasma therapy.
Meanwhile, Dr Randeep Guleria, director of AIIMS and one of the experts leading the country’s novel coronavirus disease response, has also said cell-mediated immunity, an immune response that does not involve antibodies, may also be protecting the body.
It’s pointless to tell people not to get paranoid and to remain calm. There’s much that we need to know about how Covid-19 patients are being handled in our own state. Sure we got a detailed report about how the four Covid deceased persons expired and we have to remain content with these medical reports in the absence of any scientific critique. But whether the state can handle a surge in cases remains untested. NEIGRIHMS as far as we know has received no special assistance from the Union Health Ministry to tackle the pandemic. Yet the Institute is responding and doing its utmost. The Shillong Civil Hospital transfers all complicated Covid-19 cases needing ICU facilities and other treatment facilities to NEIGRIHMS. But is the State Government actually concerned about NEIGRIMHS capacity to carry on? Is the State Government sharing its Covid response funds with NEIGRIHMS? This merits some transparency.
Coming to the point about whether naming Covid+ive persons is ethical or not, perhaps here too the medical community ought to take a local rather than a universal view. Considering that Meghalaya is battling to provide isolated quarantine for people testing Covid+ on a daily basis, it might help the rest of us if we know whether we have been in contact with a primary or secondary source. It will also help the government to conserve its resources, trying to track down contacts (many of whom prefer to remain incognito, nay even hidden). We have come to a point where any of us could get the virus. A society that is upfront will handle this pandemic better than a secretive one and the Government should not aid and abet this enigma by playing a game of hide and seek with us the public.
Let’s not push people to play guessing games each day about, “Who’s next?”
(Views expressed in this column are personal and do not necessarily reflect the stand of this newspaper).