The mRNA technique may mean that future pandemics can be dealt with far quickly. The vehicle is available to carry the next vaccine
All the usual caveats apply: Don’t go out and celebrate. Don’t let your guard down because it is still going to be a long haul. This winter will be “hard”, warns Ugur Sahin, co-founder and CEO of BioNTech, the German company that announced the first effective Covid-19 vaccine recently. “The vaccine can’t be rolled out fast enough to reduce infections much in the current wave,” he says.
The publication on November 16 of positive results for a second vaccine, this time by the US company Moderna, strengthened the optimism as did the fact that the AstraZeneca vaccine is also ready to roll out, even if it does have an average efficacy of just 70 per cent. Clearly, this Coronavirus can be beaten, and there are nine more potential Covid-19 vaccines already in the third and final stage of human trials.
But again, the riders: There will be at least half a million more Covid-19 related deaths this winter — or over a million if people don’t observe the lockdowns and other restrictions like social distancing and use of sanitisers and face masks that are meant to contain the spread of the virus.
“What is absolutely essential,” says Sahin, “is that we get a high vaccination rate before autumn/winter next year.” That’s when it could really be over. And yet there is cause to celebrate, because of the 11 vaccine candidates that were already in third-stage trials, both the front-runners are “messenger ribonucleic acid” (mRNA) vaccines, an entirely new approach that allows a much faster response to Novel viral infections.
Traditionally, new vaccines took around ten years to be developed, tested and approved for general use. For the new mRNA vaccines, it has been ten months. It’s a revolutionary science at work here.
After Chinese scientists posted the full genetic sequence of the Covid-19 virus online on January 10, says Drew Weissman of the University of Pennsylvania, “we were making RNA within a week or so”. Weissman then supplied that RNA to both BioNTech/Pfizer and Moderna.
RNA carries the genetic instructions from the nucleus of the cell to build whatever protein is needed, and for the past decade researchers have been trying to fabricate “messenger RNA” that could be inserted into human cells. The mRNA would then use the cell’s own genetic machinery to make vaccines and other medically useful proteins.
By 2018, several companies had cracked the problem of getting the mRNA past the body’s immune defences. With the full RNA sequence of the new Coronavirus in their possession, all they had to do was choose which bit of the Coronavirus RNA to use in the vaccine.
Obviously not the whole thing, or it would rebuild the entire virus in the cell. Just a harmless segment of the virus’ RNA, copied millions of times by the vaccinated person’s cells, would alert the body’s immune system and train it to destroy any invading virus with that sequence. Scientists chose the “spike” that the virus uses to attach itself to the human cell.
Several companies had mRNA vaccines ready for testing within two or three months, and the results have been spectacular. BioNTech/Pfizer has just reported 95 per cent efficacy for its vaccine and Moderna has reported 94.5 per cent success.
Even better, both BioNTech/Pfizer and Moderna included all major ethnic groups and a significant number of elderly people in their third-phase trials. All categories responded well to the shots (which is not always the case with trial vaccines).
Yet another mRNA vaccine in third-phase trials could be even better because it will be far cheaper than the BioNTech/Pfizer vaccine (priced at Rs 2,896 for two shots) or the Moderna jab (priced at Rs 5,495 for two shots) if it pans out. At Imperial College in London, Robin Shattock’s team is working on a “self-amplifying RNA” vaccine that may require as little as one-hundredth of the amount of vaccine.
The mRNA technique may mean that future pandemics can be dealt with far more quickly. The vehicle is already available and waiting to carry the next vaccine. Just “plug and play” for any future Coronavirus, as one researcher puts it. (We have had three new Coronaviruses in the last two decades.)
Pfizer boss Albert Boura goes even further to say: “It is the greatest medical advance in the last 100 years.” Well, maybe, though a vote taken today would probably plump for antibiotics instead. But we are only beginning to see the potential of the mRNA technique. There are already trials under way for a wide variety of other illnesses. Not just safer, more effective influenza, polio and HIV vaccines, but immunotherapies for cancer, heart conditions, cystic fibrosis and other systemic and congenital diseases.
Whether or not mRNA now becomes the preferred way to make Novel vaccines, it is clear that a global health emergency on the scale of the present pandemic spurs scientific innovation at a much faster rate now. This is not just the consequence of all the resources and funding made available to those with solutions that might usually be regarded with more scepticism; it is also driven by the remarkable things that humans can achieve when thrust together by circumstances and given a common purpose.
There is a long, dark winter still ahead of us, no doubt, but miracles may await us over the horizon. And we can now be sure that the light at the end of this particular tunnel is not an oncoming train.
(Gwynne Dyer’s new book is ‘Growing Pains: The Future of Democracy and Work’)
The AstraZeneca vaccine has been clinically tested to have an average efficacy of 70 per cent. We still need containment drills
With India clearly in the midst of a third wave — some might even call it a tsunami of new Coronavirus cases — we should not be surprised. Even a cursory glance of what happened during the 1918-1919 Spanish influenza pandemic should have warned us to be prepared for winter, because even a century ago, there was a massive increase in cases in winter when the cold compromises lungs thanks to congestion and any influenza virus can be devastating. With the Delhi and Gujarat governments in a state of panic, it is almost certain that cases will begin to increase across the country whether the authorities admit to them or not. But there is some positive news with British pharmaceutical firm AstraZeneca, which has jointly developed a vaccine with University of Oxford to combat the Coronavirus, coming out with its trial results. That is because the Serum Institute of India (SII) has been a partner to this research as well and has promised that it will produce hundreds of millions of doses of this vaccine for Indians. Yet, the results have only indicated an average of 70 per cent efficacy with two full doses taken a month apart and up to 90 per cent when an initial half dose is combined with a full dose taken after one month. Promisingly, the vaccine doesn’t need super-cold storage like the ones developed by Pfizer and Moderna, requiring only refrigeration. It also appears that as many as five other promising vaccine candidates might make it to the markets by early 2021.
However, as we have maintained, the development of a vaccine is not equal to its deployment. Also, if as the trials have indicated, with at least one-and-a-half doses required for maximum efficacy, India will need a whopping two billion doses. Even if costs are kept in check, this is looking at a time frame that might take well over three-four years to inoculate a substantial number of Indians in order to gain a decent amount of protection. At the same time, because efficacy is not the same as effectiveness, even with 90 per cent efficacy, the Coronavirus will continue to pop up, tens of thousands will continue to get infected and many more will die before the Wuhan pandemic truly settles down. Till then, preparedness and preventable behaviour are the only containment devices against an unexpected surge and given India’s population density, we better reconcile ourselves to the fact that our crests will be a constant for some time. Maharashtra, which has been the worst-affected State in the country, fighting the longest battle and is now threatened with a new front, has finally released its new screening SOPs that make a RT-PCR test report mandatory for visitors who are travelling to the State from hotspots. All entry points to the State will have testing and screening centres for those not carrying such a report. This is the first time that international travel protocols are being followed domestically and perhaps would be adopted by other States, too, to keep the numbers down. It is a shame indeed that the Supreme Court has had to pull up State Governments on laxity and seek a status report on preparedness. The court also had to get into the nitty gritties of ensuring dignified treatment of the dead and vetting hospital conditions to treat the sick. A fatigue has undoubtedly set in, socially, psychologically and physically. Doctors are the worst affected, some of whom need to be relieved with younger colleagues now being drafted in to ease frontline pressure. Anticipation is the best defence now. The pandemic has forced Governments to invest in public health like never before but now investments in vaccine manufacturing and deployment will be the challenge. These are positive developments but let us not pretend that the news of a vaccine is a silver bullet that will magically cure the world.
We need public-private partnerships to meet targets as our existing immunisation drives are quite under-served
Since 2020 has been “a lost year”, engulfed as it has been by the pandemic, many are looking forward to 2021 as “the year of the vaccine.” And when it comes to India, a year would still fall short of inoculating its people. As Adar Poonawalla, the CEO of the Serum Institute of India, which is the world’s largest vaccine manufacturer and will be rolling out the Oxford vaccine, predicted that it could take till 2024 to secure all Indians. If containing the virus is level 1 of the challenge, vaccinating people against it is level 2 indeed. The toughest, of course, would be devising the logistics of the supply chain, ensuring the safety of the vials, avoidance of wastage and lining up trained health workers to administer the vaccine and monitor its effects on the recipients. In fact, given India’s population, there has to be a multi-phased, general election-like drill and efficiency, all of which cost money and resources. Poonawalla himself estimated a Government spend of Rs 80,000 crore in one year. Of course, though we have not yet had an adult immunisation programme, the Government will be riding piggyback on the existing immunisation network for women and children, one of the world’s largest. But we have to reckon with some cold facts considering that our Universal Immunisation Programme is yet to achieve 100 per cent success and is still struggling to meet targets despite years of investment and efforts. An IndiaSpend survey of September 2019 shows that 47 per cent of India’s poorest children are not fully immunised, 17 per cent more than the richest ones, leaving them prone to preventable diseases that compound the burden of healthcare costs for their families. Although Government immunisation programmes have been carried out for 30 years, the coverage rate has been growing at a snail’s pace. According to the Health Ministry’s own findings, India’s vaccination coverage increased from 35 per cent in 1992-93 to 62 per cent in 2015-16. Only 16 districts in India have a coverage of over 90 per cent. Currently our immunisation shield targets 26.7 million newborns and 29 million pregnant women every year, which works to around 390 million doses of vaccines. Needless to say the pandemic has slowed down the pace and efficacy of drives this year. Assuming we can tap into this network immediately, we will still need to supplement its strength and capacities to administer 400-500 million doses by the first two quarters of 2021. Also, a two-shot vaccination drive would mean double the effort. Much has already been said about the challenges of a contiguous cold chain infrastructure that includes moving contained, sanitised and temperature-controlled vaccine consignments under tropical conditions and ensuring last mile equity. The first vaccines announced by Pfizer and Moderna require sub-zero conditions; they must be thawed from -70 degrees celsius and injected within five days. Or else, the whole consignment could go bad. Such delicacy of maintenance and administering doses require a sophisticated and expensive infrastructure that India and even other developing countries would find difficult to harness at short notice. We would have to look at a vaccine that can be stored and transported in liquid form (anything between two and eight degrees celsius) instead of the frozen kind. Besides, no vaccine has a 100 per cent efficacy or can claim a lifetime guarantee — a shot could have to be repeated if antibody levels drop before the predicted periodicity. Some nations would then have to wait for a more conventional vaccine that brews batches of protein or inactivated viral particles in living cells, has the same effect as that of the pharma majors, and can be delivered through existing health care networks. We need to prepare allied items like syringes and glass vials and since glass breaks at sub-zero temperatures required of the announced vaccines, it needs to be a toughened and fortified kind. Even these need to be tested for the vaccine’s stability and subjected to laboratory approvals. These need to be started right away if we want a good stock ready to seal the vaccines. We may be privileged to produce and supply the bulk of the world’s vaccines but can we deliver it to every Indian in the hinterland and protect communities even as managing cities themselves may pose a challenge?
There are no dilemmas really. Nations rich in resources and with an evolved health infrastructure will be deploying the Pfizer and Moderna vaccines before ours. And though the World Health Organisation’s Covax project intends to raise $18 billion to buy stocks for poorer countries, the trickle-down effect would be delayed, creating a new kind of healthcare hierarchy. Asia, Africa and South America, even with emergent economies, would need an all-new template in the health sector. There are huge recurring costs involved with vaccines made in one part of the world required to be transported to another. And given their fragile and unstable nature, they would mostly be airlifted. Analytics firm McKinsey has estimated that over 10 billion doses would be traded globally. Planes, trucks, warehouses and health centres will have to be outfitted with freezers. The last implies an uninterrupted electricity supply. How many villages and district towns in India can afford continuous power supply? Even with back-ups and generators, how many health centres can sustain the added costs? The Government immediately needs to involve the private sector in developing the delivery and distribution infrastructure in right earnest. It can use Digital India programmes to map the supply chain requirements, track the response modules and effectively manage and deploy resources. The pandemic has taught us how health is the real wealth of a nation. Even if we tame COVID-19, it won’t be the last. We have to reconfigure health and human resource as a major driver of the economy going forward.
An urgent action plan is mandatory while integrative and coordinated efforts from all stakeholders are required to respond to a looming threat
In spite of global efforts to contain and mitigate the Coronavirus outbreak, the world is still battling the pandemic, with a number of countries facing recurrent peaks. Our own national Capital has been grappling with an upsurge of Covid-19 cases with the start of the winter season, which usually sees the city enveloped in smog.
There has been a sharp rise in the number of Covid-19 patients (7,000 to 8,000 cases daily) in the last three weeks due to the dangerous cocktail of an early winter and Coronavirus fatigue. The last saw huge crowds mill around markets, restaurants and private parties. This is the third surge of cases following the first peak in late June and the second peak in September. This is actually in line with my prediction of multiple waves of Covid-19 happening in India, in these columns in June. This also reflects our understanding of different peaks occurring in various parts of India at different times.
This has been the trend across the globe with the pandemic behaving in a similar way, be it in America where the cases rose sharply in one State and then moved across gradients to affect another State. Many countries in Europe, too, have experienced a similar phenomenon of multiple waves of the pandemic at different times.
It is not just the number of new cases that is worrying. The more devastating factor is the number of daily deaths, almost one hundred in the last week itself in Delhi. So far, the national as well as Delhi’s Covid-19 case fatality rate has been reported to be one of the lowest in the world with an improving recovery rate. However, since the cases are surging, the number of daily deaths is bound to rise, too, owing to the fragile healthcare system, which is buckling under the pressure of the rising infections.
It was expected that cases will go up with the double whammy of crowds during the festival season along with the increased infectivity of the Coronavirus due to the surge of influenza-like illnesses in the winter months. However, the air pollution has made matters worse.
Pollution not only hampers the capacity of our lungs to clear the Coronavirus infection but particulate matter or pollutants can also facilitate its transmission by acting as a vehicle for large droplets which tend to stay suspended longer and lower down in the environment. These can infect more people.
There is enough evidence now that there is a direct relation between high PM2.5 levels and increased infectivity of the Coronavirus as shown in studies from China, the UK and Italy during this pandemic. It is also pertinent to know that the new positive cases being reported as of now are the reflection of exposure and infections which occurred in the previous weeks. There is a lag between exposure and clinical symptoms due to the incubation period of the viral infection, which is anything between two to 14 days for the SARSCoV2 virus. Therefore, the new positive cases represent the infections occurring five to seven days preceding the reports.
Similarly there is a lag between exposure, clinical symptoms and the need for ICU admissions and assisted ventilation and fatalities in severe cases of Covid-19. This period is usually 10 to 14 days.
It is important to understand this lag period as the number of deaths being reported today is reflective of infections occurring at least two weeks ago, since deaths lag behind infections by weeks.
This is an important implication as the number of new positive cases is bound to increase tremendously in the coming two weeks post-Diwali due to compounded effects of over crowding, air pollution, bursting of crackers and the cold weather. It is quite predictable that the coming two weeks will be crucial, both in terms of new positive cases, the number of fatalities and the unfolding of a serious situation. Therefore, an urgent action plan is mandatory and integrative and coordinated efforts from all stakeholders are required to respond to this looming scenario.
First, containment and mitigation measures, which slow down the spread, are the only options in the face of the unrelenting infection phase, while augmentation of infrastructure in terms of ICU beds and trained manpower in critical care, are crucial to prevent deaths. Provision of ICU beds is not the solution unless we have enough trained manpower to manage the severe Covid-19 patients and run these critical care facilities.
Moreover the fundamentals of containment and mitigation remain the same, including sanitising, masking and distancing. We all know the drill but it is crucial to enforce behavioural changes like in the case of driving laws.
Second, since the positivity rate in Delhi (15 per cent) is too high, which is more than three times than the national average, there is no other option but to scale up testing to contain the spread of the infection. This needs to be brought below five per cent consistently to ensure adequate testing is being done.
There has been more of the rapid antigen testing in Delhi and fewer RT-PCR tests, a formula which needs to be reversed. Ideally all the tests should be RT-PCR tests, which are more sensitive and would pick up more cases. Moreover anyone who undergoes the test should remain in quarantine till they get the results to limit transmission of the infection.
There needs to be a two-stage house-to-house cluster sero surveillance, as is being done in countries with robust healthcare systems. This ensures identification of people with symptoms of Covid-19. The RT-PCR testing for them confirms active infection and measures the quantum of past infection through antibody testing.
This strategy would not only mitigate cases but also help policy-makers plan a public health response in the coming months. We need to act aggressively and quickly to save lives and avoid preventable deaths. The time to act proactively is now to save each and every life in the coming weeks. The fact remains that the virus is here to stay and the vaccine is still miles away.
(The writer is Head of Neurology Department, Lady Hardinge Medical College and SSK Hospital)
With several firms announcing good news on a COVID-19 vaccine, have we turned a corner on the pandemic?
There has been a lot of good news on the search for a vaccine to combat Covid-19, the pandemic that ripped the year to shreds. With news from Pfizer-BioNTech and Moderna stating that their vaccines have 90 and 94.5 percent efficacy respectively even as the final stages of trials begin, hope now seems a possibility. The Russians have claimed their Sputnik-V vaccine confers an efficacy of 92 per cent but those claims are being taken with a pinch of salt. Elsewhere, several other vaccine-candidates are reaching the final stages of their development, including India’s COVAXIN, developed by Bharat Biotech. It appears that by early 2021 at least one if not more vaccines would have been released in the market.
That said, we must temper our enthusiasm slightly as most vaccines so far require incredibly super-cold chain transportation requirements. The Pfizer vaccine needs temperatures below -80 degrees centigrade to be stable, the Moderna one, a very cold but slightly more reasonable -20C. It will be difficult to manage such a cold chain vaccine delivery system, particularly in a country the size of India, but one could assume that hardier vaccines will be developed which India’s existing cold chain infrastructure developed for fish, meat and vegetables will be able to manage. However, even if such a vaccine is developed relatively soon, one should beware that it might take several months to inoculate most Indians living in large metropolitan areas even if we take advantage of producing companies like the Serum Institute. Safely manufacturing and deploying over a billion doses of the vaccine, even if global suppliers help with patents and manufacturing, could take years. But getting the vaccine out there as soon as possible will, according to some virologists, dramatically speed up the herd immunity process. It is not surprising that stock exchanges across the world have been on the upswing as have reports from bodies looking at economic growth. After almost a whole year of doom and gloom, even a bit of positive news is enough to set the markets rocking. And make no mistake, all these reports are very positive. Yet, we would have to be cautious until we get the nitty-gritties of how exactly the vaccine will be administered.
Trump is challenging the timing of Pfizer’s COVID vaccine as politically motivated, says he is being robbed of credit due to him
The vaccine that was supposed to hand a beleaguered US President Donald Trump his second term in office is finally here but it is a tad too late to be of any help to him. Pfizer and German biotechnology company BioNTech have announced that their Coronavirus vaccine was more than 90 per cent effective in phase three large-scale clinical trials. It has been developed outside the White House’s Operation Warp Speed programme, although the Trump administration placed an initial order for 100 million of the firm’s vaccine doses for $1.95 billion in July. Operation Warp Speed pumped billions of dollars into six other pharmaceutical companies intended to accelerate vaccine development. Even as there was a political storm over the timing of the announcement, President-elect Joe Biden, who made his criticism of Trump’s handling of the pandemic a centrepiece of his election campaign, congratulated the “brilliant women and men” involved in the research. But he didn’t go overboard and urged the nation to continue wearing masks and maintaining protocols as it would be “many more months before there is widespread vaccination.” Biden’s appeal assumes significance because Trump had repeatedly mocked the former for wearing the face cover during election campaigns. Many Conservatives even contended that masks infringed on their individual freedom. This stubbornness to ignore the advice of experts on Corona protocols has been widely blamed for the fact that the US remains the worst-hit country in the world.
Coming close on the heels of the mandate, the US President, who will be legally challenging the vote count on the grounds of it being a fraud, will also be using the vaccine claim as part of a conspiracy theory. In a renewed push to justify his victimhood, he felt that the US Food and Drug Administration (USFDA) was politically motivated and should have announced it earlier to save lives. Of course, he disregarded the fact that the scientific community across the world had sworn that they would not be compromised by political arm-twisting and would declare results after they were absolutely sure of trials. The findings may have come in the natural and ethical course of protocols but Trump is not going to let go of the opportunity to claim he fast-tracked it and now was being cheated out of the credit due to him. Vice-President Mike Pence, too, was quick to point out that the vaccine was a result of the Trump administration’s “public-private partnership” initiative. Be that as it may, the fact remains that Trump and Co are responsible for the Corona soup the US is in today and the verdict of the people was against that and the divisive policies based on ethno-nationalism. As far as Biden is concerned, the vaccine will be the cherry on the cake. But will he get rid of “Trumpism” that will dog every move he makes?
Till we increase the share of swab testing in mapping the pandemic, we won’t get a grip on the city’s caseload or address it
Just as was being feared by healthcare experts and those who have been following the trajectory of the pandemic globally, Delhi is seeing a massive surge in Coronavirus infection after a brief lull. Worryingly, Delhi recorded over 7,000 COVID-19 cases for the first time with a 12 per cent positivity. The only silver lining is that the recovery rate was over 89 per cent and that 57 per cent of the 15,789 dedicated COVID beds are vacant in the city, making it easier for people with severe symptoms to get admitted. But not for long. Of course, the triggers are many, namely the festive rush, the pandemic fatigue that has made people drop guard and the early onset of winter and pollution that anyway aggravate lung diseases.
In part, the recent spike in infections can also be attributed to the fact that the Delhi Government in coordination with the Centre had opted for aggressive contact tracing and monitoring of quarantined patients to suppress and break the chain of transmission. The focus is on critical zones, restaurants, marketplaces, barber shops and salons because random testing hadn’t recorded as many cases. This is part of a strategy to contain the spread of COVID-19 in Delhi with the Health Ministry and experts recommending targetted RT-PCR testing in sensitive and critical zones. Hence, with more testing and contact tracing, the numbers were bound to go up. But it seems that the trusted RT-PCR or swab testing, which is currently around 23 per cent, needs to be extended as much as possible because over-reliance on antigen tests is blocking disease-mapping. A large number of positive cases would have slipped through the cracks because about half of the antigen tests register false negatives, which means that the current figures could double if all those tested by the antigen method were subjected to RT-PCR reviews. Perhaps that’s the reason why the authorities are now recommending that a suspect with persistent symptoms take the golden test even if s/he has cleared the antigen one. The danger of antigen tests is that an asymptomatic carrier of the infection, if found negative, will get a false sense of security and can turn super-spreader. Besides, somewhere the operational preparedness of the summer peak has led to a sense of complacency. Back then, the tiered approach of ramping up infrastructure, testing and operationalising a home care system with oximeters to COVID-affected families was synchronised to contain the spiral. The fall in figures in between has clearly led to laxity in maintaining a coordinated response system. The Delhi Government is probably considering moving the Supreme Court to vacate the High Court’s stay on reserving 80 per cent COVID ICU beds for people of Delhi. But would that stem the tide as families are split across NCR and not seem exclusivist? Testing the right way is the only way out. At the same time, Delhiites need to ride out the winter indoors if they don’t want another insurmountable crisis on their hands.
The curriculum of medical education seems to focus essentially on the institution of hospitals. The results are there for all to see
The public healthcare system in India is one of those topics on which most people have an opinion. It is often expressed with much energy and claimed insight. There are some favourite viewpoints. Almost all of them talk of primary, secondary and tertiary healthcare. Usually, a discourse on these aspects is accompanied by half a tear on the state of affairs in the country. The truth is that notwithstanding the enthusiasm for allopathic healthcare, this country’s primary healthcare system is nourished and sustained by Indian systems of medicine. They are easily available, the diagnosis is simple and in a large number of cases the results are satisfactory. Traditional medicine systems do not burden the common man with endless medical tests like allopathy does, which in turn are often accompanied by protestations about the possible unreliability of the results. This is not only because of the nature of the tests but also due to the flaws in the process of testing. Often, the search for reliability means repeat tests. Interestingly, the pathology labs, as a source of livelihood, have very rarely been subjected to an analysis which tries to understand their exponential growth. Cartels are reported to be rampant in B and C-class cities, not to overlook the groupings in the smaller geographical units of megacities. It is one of those strange situations when a lot of people know what’s going on and yet nobody wants to talk about it. When talking itself is taboo, one can well imagine the plight of a possible investigation of a serious order.
Strangely enough, an engineer in the process of becoming one has to undergo certain orientations in social sciences or cognate areas. By and large, the curriculum of medical education seems to have its focus essentially on the institution of hospitals. The results are there for all to see.
The Covid era has lent these traits a grotesque veneer. By and large these days, hospitals tend to avoid giving a discharge certificate which would say whether the patient has been cured (or not) of Covid. Senior doctors take shelter behind the Indian Council of Medical Research’s guidelines. Perhaps some of this is unavoidable, yet there are cognate issues which await clarity. National protocols need to prevail but when will there be greater specificity?
The merits of this can be debated. Some will claim that it is inherent in a situation like the ongoing pandemic, where so little is known about the virus. One of the media write-ups talked of seven types of mild-Covid. Notwithstanding this categorisation, apparently there is very little to distinguish the treatment of one Coronavirus from the other. Paracetamol et al is administered in each case and here enters the fanciful word-of-the-year: “Immunity.” The last 11 months have seen this word riding the crest as never before in human history. The Indian healthcare systems, which subscribe to “the-way-of-life being the route to health and happiness” doctrine, seem to be having the last laugh.
Right from amla to apricot, everything has become a panacea and the source of immunity and health that people swear by. It doesn’t seem to bother many that apricot itself is a seasonal fruit and cannot be the route to universal and sound health.
The second and the third waves of Covid have become a widespread topic of discussion in most drawing rooms across the country. As winter approaches and cases spike, much of Europe is undergoing or threatening to undergo another spell of lockdown. Interestingly enough, few authentic figures are available of what percentage of the spike is a result of relapsed cases in patients, who were discharged from hospital even though they had met the existing protocol of release. The ambiguity of the situation may be partly inherent but it still does not explain why the issues of treatment of different categories of Covid patients are not being pushed to their logical conclusion.
Is it not prudent to keep the patient under the care of the same set-up for a longer period of time before s/he is allowed to travel and there is reasonable guarantee that the person will not be a candidate for a repeat infection? It is obvious that it is difficult to give firm answers to these tricky questions. However, it is pathetic that the broad contours of the situation are not being sufficiently discussed. There is a need to recognise this aspect and take it on board for a deeper analysis and remedy.
Clearly, the powers that be, the medical fraternity and civil society, must come to grips with the situation. These are, indeed, not the only imponderable issues needing far-more concerted attention. But they are important nonetheless.
(The writer is a well-known management consultant of international repute)
I had no alternative but to die or to try to find a cure for myself. I am a scientist - surely there was a rational explanation for this cruel illness that affects one in 12 women in the UK?
I had suffered the loss of one breast, and undergone radiotherapy. I was now receiving painful chemotherapy and had been seen by some of the country’s most eminent specialists. But, deep down, I felt certain I was facing death. I had a loving husband, a beautiful home and two young children to care for. I desperately wanted to live.
Fortunately, this desire drove me to unearth the facts, some of which were known only to a handful of scientists at the time.
Anyone who has come into contact with breast cancer will know that certain risk factors - such as increasing age, early onset of womanhood, late onset of menopause and a family history of breast cancer - are completely out of our control. But there are many risk factors, which we can control easily.
These “controllable” risk factors readily translate into simple changes that we can all make in our day-to-day lives to help prevent or treat breast cancer. My message is that even advanced breast cancer can be overcome because I have done it.
The first clue to understanding what was promoting my breast cancer came when my husband Peter, who was also a scientist, arrived back from working in China while I was being plugged in for a chemotherapy session.
He had brought with him cards and letters, as well as some amazing herbal suppositories, sent by my friends and science colleagues in China.
The suppositories were sent to me as a cure for breast cancer. Despite the awfulness of the situation, we both had a good belly laugh, and I remember saying that this was the treatment for breast cancer in China, then it was little wonder that Chinese women avoided getting the disease.
Those words echoed in my mind. Why didn’t Chinese women in China get breast cancer? I had collaborated once with Chinese colleagues on a study of links between soil chemistry and dis-ease, and I remembered some of the statistics.
The disease was virtually non-existent throughout the whole country. Only one in 10,000 women in China will die from it, compared to that terrible figure of one in 12 in Britain and the even grimmer average of one in 10 across most Western countries. It is not just a matter of China being a more rural country, with less urban pollution. In highly urbanized Hong Kong, the rate rises to 34 women in every 10,000 but still puts the West to shame.
The Japanese cities of Hiroshima and Nagasaki have similar rates. And remember, both cities were attacked with nuclear weapons, so in addition to the usual pollution-related cancers, one would also expect to find some radiation-related cases, too.
The conclusion we can draw from these statistics strikes you with some force. If a Western woman were to move to industrialized, irradiated Hi-roshima, she would slash her risk of contracting breast cancer by half. Obviously, this is absurd. It seemed obvious to me that some lifestyle factor not related to pollution, urbanization or the environment is seriously increasing the Western woman’s chance of contracting breast cancer.
I then discovered that whatever causes the huge differences inbreast cancer rates between oriental and Western countries, it isn’t genetic.
Scientific research showed that when Chinese or Japanese people move to the West, within one or two generations their rates of breast cancer approach those of their host community.
The same thing happens when oriental people adopt a completely Western lifestyle in Hong Kong. In fact, the slang name for breast cancer in China translates as ‘Rich Woman’s Disease’.
This is because, in China, only the better off can afford to eat what is termed ‘Hong Kong food’.
The Chinese describe all Western food, including everything from ice cream and chocolate bars to spaghetti and feta cheese, as “Hong Kong food”, because of its availability in the former British colony and its scarcity, in the past, in mainland China.
So it made perfect sense to me that whatever was causing my breast cancer and the shockingly high incidence in this country generally, it was almost certainly something to do with our better-off, middle-class, Western lifestyle.
There is an important point for men here, too. I have observed in my research that much of the data about prostate cancer leads to similar conclusions.
According to figures from the World Health Organization, the number of men contracting prostate cancer in rural China is negligible, only 0.5 men in every 100,000. In England, Scotland and Wales, however, this figure is 70 times higher. Like breast cancer, it is a middle-class disease that primarily attacks the wealthier and higher socioeconomic groups, those that can afford to eat rich foods.
I remember saying to my husband, “Come on Peter, you have just come back from China. What is it about the Chinese way of life that is so different?”
Why don’t they get breast cancer?’ We decided to utilize our joint scientific backgrounds and approach it logically. We examined scientific data that pointed us in the general direction of fats in diets.
Researchers had discovered in the 1980s that only l4% of calories in the average Chinese diet were from fat, compared to almost 36% in the West.
But the diet I had been living on for years before I contracted breast cancer was very low in fat and high in fibre.
Besides, I knew as a scientist that fat intake in adults has not been shown to increase risk for breast cancer in most investigations that have followed large groups of women for up to a dozen years.
Then one day something rather special happened. Peter and I have worked together so closely over the years that I am not sure which one of us first said:
“The Chinese don’t eat dairy produce!” It is hard to explain to a non-scientist the sudden mental and emotional’ buzz’ you get when you know you have had an important insight. It’s as if you have had a lot of pieces of a jigsaw in your mind, and suddenly, in a few seconds, they all fall into place and the whole picture is clear.
Suddenly I recalled how many Chinese people were physically unable to tolerate milk, how the Chinese people I had worked with had always said that milk was only for babies, and how one of my close friends, who is of Chinese origin, always politely turned down the cheese course at dinner parties.
I knew of no Chinese people who lived a traditional Chinese life who ever used cow or other dairy food to feed their babies. The tradition was to use a wet nurse but never, ever, dairy products. Culturally, the Chinese find our Western preoccupation with milk and milk products very strange. I remember entertaining a large delegation of Chinese scientists shortly after the ending of the Cultural Revolution in the 1980s.
On advice from the Foreign Office, we had asked the caterer to provide a pudding that contained a lot of ice cream. After inquiring what the pudding consisted of, all of the Chinese, including their interpreter, politely but firmly refused to eat it, and they could not be persuaded to change their minds.
At the time we were all delighted and ate extra portions! Milk, I discovered, is one of the most common causes of food allergies. Over 70% of the world’s population are unable to digest the milk sugar, lactose, which has led nutritionists to believe that this is the normal condition for adults, not some sort of deficiency. Perhaps nature is trying to tell us that we are eating the wrong food.
Before I had breast cancer for the first time, I had eaten a lot of dairy produce, such as skimmed milk, low-fat cheese and yogurt. I had used it as my main source of protein. I also ate cheap but lean minced beef, which I now realized was probably often ground-up dairy cow.
In order to cope with the chemo-therapy I received for my fifth case of cancer, I had been eating organic yogurts as a way of helping my digestive tract to recover and repopulate my gut with ‘good’ bacteria.
Recently, I discovered that way back in 1989 yogurt had been implicated in ovarian cancer. Dr Daniel Cramer of Harvard University studied hundreds of women with ovarian cancer, and had them record in detail what they normally ate. Wish I’d been made aware of his findings when he had first discovered them.
Following Peter’s and my insight into the Chinese diet, I decided to give up not just yogurt but all dairy produce immediately. Cheese, butter, milk and yogurt and anything else that contained dairy produce - it went down the sink or in the rubbish.
It is surprising how many products, including commercial soups, biscuits and cakes, contain some form of dairy produce. Even many proprietary brands of margarine marketed as soya, sunflower or olive oil spreads can contain dairy produce
I therefore became an avid reader of the small print on food labels. Up to this point, I had been steadfastly measuring the progress of my fifth cancerous lump with callipers and plotting the results. Despite all the encouraging comments and positive feedback from my doctors and nurses, my own precise observations told me the bitter truth.
My first chemotherapy sessions had produced no effect - the lump was still the same size. Then I eliminated dairy products. Within days, the lump started to shrink
About two weeks after my second chemotherapy session and one week after giving up dairy produce, the lump in my neck started to itch. Then it began to soften and to reduce in size. The line on the graph, which had shown no change, was now pointing downwards as the tumour got smaller and smaller.
And, very significantly, I noted that instead of declining exponentially (a graceful curve) as cancer is meant to do, the tumour’s decrease in size was plotted on a straight line heading off the bottom of the graph, indicating a cure, not suppression (or remission) of the tumour.
One Saturday afternoon after about six weeks of excluding all dairy produce from my diet, I practised an hour of meditation then felt for what was left of the lump. I couldn’t find it. Yet I was very experienced at detecting cancerous lumps - I had discovered all five cancers on my own. I went downstairs and asked my husband to feel my neck. He could not find any trace of the lump either.
On the following Thursday I was due to be seen by my cancer specialist at Charing Cross Hospital in London. He examined me thoroughly, especially my neck where the tumour had been. He was initially bemused and then delighted as he said, “I cannot find it.” None of my doctors, it appeared, had expected someone with my type and stage of cancer (which had clearly spread to the lymph system) to survive, let alone be so hale and hearty.
My specialist was as overjoyed as I was. When I first discussed my ideas with him he was understandably sceptical. But I understand that he now uses maps showing cancer mortality in China in his lectures, and recommends a non-dairy diet to his cancer patients.
I now believe that the link between dairy produce and breast cancer is similar to the link between smoking and lung cancer. I believe that identifying the link between breast cancer and dairy produce, and then developing a diet specifically targeted at maintaining the health of my breast and hormone system, cured me.
It was difficult for me, as it may be for you, to accept that a substance as ‘natural’ as milk might have such ominous health implications. But I am a living proof that it works and, starting from tomorrow, I shall reveal the secrets of my revolutionary action plan.
Extracted from Your Life in Your Hands, by Professor Jane Plant
Forty five-year-old Ayesha (name changed), a resident of a small town in west Uttar Pradesh (UP), first spotted a tiny painless lump in her breast in April this year. However, the Coronavirus- induced lockdown and the fear of catching the infection in a healthcare setting prevented her from seeing a doctor. Even when the lockdown was eased, her family was too scared to travel to Delhi to seek medical consultation. By the time she reached an oncologist four months later, her aggressive cancer had already hit Stage III, diminishing the chances of her survival.
Unfortunately, Ayesha is not a lone case of a seriously-ill patient being deprived of timely treatment due to the ongoing contagion. While we will never be able to collate data of how many such patients suffered delayed diagnosis and treatment this year, it is evident that the number is significant. Patient attendance in oncology clinics fell significantly in the initial months of the pandemic. The number of new cases diagnosed continued to remain relatively low even several months after the total lockdown had been eased. Breast Cancer Now, a British charity organisation, estimated that due to the contagion almost a million British women had missed a screening appointment. This might have led to thousands of cancers going undetected. For a country like India, where a majority of breast cancer detections still happen in the later stages of the disease, the Coronavirus outbreak has further hampered diagnosis and treatment, and is likely to negatively impact survival rates from the disease.
Rising disease burden in India: Breast cancer is the most common form of the disease among Indian women and accounts for an estimated 28 per cent of all cancers. In fact, a woman is diagnosed with it every four minutes while another dies of this disease every 13 minutes in the country. In 2018, it is estimated to have claimed as many as 87,000 lives in India. The incidence of the disease has increased dramatically over the last 25 years due to multiple factors, including increasing urbanisation, adoption of unhealthy lifestyles (smoking, drinking, junk food consumption and so on), increased use of plastic utensils and microwave ovens, rise in obesity, drop in physical activity levels, delayed age of child-bearing and reduced breast-feeding.
India also has a high mortality rate because a majority of the patients are still diagnosed in the late stages of the disease and a significant proportion of them are not able to get appropriate treatment. Another worrying trend is an increasing incidence of the disease in younger women. Shockingly, nearly half of the patients in urban India are less than 50 years of age. Poor awareness about symptoms, lack of a universal and comprehensive screening programme, social taboos and embarrassment to discuss the issue are the main reasons behind delayed diagnosis as well as the resultant high mortality. Unfortunately, the prevailing situation due to a worldwide pandemic has impeded diagnosis and treatment of a number of non-Coronavirus diseases, including all types of cancers. Already a neglected subject, women’s health has further been relegated to the back-burner as families delay medical consultation and avoid visiting healthcare facilities or undergoing regular disease screening.
Pandemic or not, do not put health issues on the back-burner: The Coronavirus is a long-term problem, which is likely to stay with us in the near future. While containing the pandemic and ensuring treatment of all infected people must be a high priority, adequate policy measures need to be taken to ensure that other serious diseases are not neglected in the process. Governments as well as healthcare providers, both have a role to play in achieving this. It is important to educate people about the importance of not neglecting their health conditions and prevent interruptions in treatment modalities, too. It is equally important to ensure continuation of unimpeded non-Coronavirus services in hospitals while also instilling confidence among people about the safety of hospitals and clinics, especially outpatient departments (OPDs).
However, the silver lining in the dark cloud is that thanks to advanced diagnostic and treatment modalities, survival rates of breast cancer patients have increased significantly globally. While survival depends on a number of factors such as the type of cancer, stage at the time of diagnosis, the quality of treatment, in the US it is estimated that up to 90 per cent of women survive five years after diagnosis and 84 per cent manage to survive 10 years.
However, in India, the survival rates remain abysmally low for reasons mentioned above. Increased awareness and health literacy, regular screening after 40 years of age, adoption of a healthy and active lifestyle sans smoking or excessive drinking, timely and appropriate treatment can help improve survival rates in India too.
New-age technologies can help navigate the Coronavirus pandemic: The adoption of new-age technologically- advanced methods further helps improve the quality of life of patients. Now, surgical treatment does not mean removal of the whole breast in all patients. It is possible to offer a breast conservation surgery in nearly 60-70 per cent of the patients either upfront or after chemotherapy.
Similarly, complete removal of armpit nodes, a procedure done routinely in all patients until a couple of decades ago, has given way to sentinel lymph node biopsy in which only a few nodes need to be tested for the presence of the tumour.
If these sentinel nodes are not involved in the disease, one does not need to remove the remaining nodes, thus bringing down the rate of shoulder dysfunction as well as lymphedema (swelling of the arm) significantly. Similar to surgery, personalised systemic therapy (chemo, hormone, immune and targeted therapy) has enabled us to avoid more toxic treatment in patients with a good biology tumour. Two patients with the same size of tumour can have very different outcomes. New-age prognostic tests help predict the risk of cancer relapse in the early stage of breast cancer with a high degree of accuracy, stratifying patients into low and high-risk categories, based on their tumour biology. Those patients who fall in the low-risk category have very limited risk of relapse and may be able to avoid chemotherapy.
Cancer patients face a higher risk of catching the Coronavirus infection as well as suffering from its complications because of their immuno-suppressive state as a result of the disease itself and due to chemotherapy. These prognostic tests that can help them avoid chemotherapy, if used judiciously, can kill two birds with one stone — patients can avoid chemotherapy, which is immunosuppressive, and avoid visits to the hospital to undergo chemotherapy.
Radiation therapy has also undergone a complete metamorphosis over the decades and modern machines enable us to deliver more precise radiation (thus sparing adjacent organs like the lungs and the heart from a high dose of radiation) and in a shorter interval of time (as less as two weeks as compared to the usual five weeks in a select group of patients).
In more good news, researchers in Canada have developed a new, inexpensive technology that could save lives and money by routinely screening women for breast cancer without exposure to radiation. The system, developed by researchers at the University of Waterloo, uses harmless microwaves and Artificial Intelligence software to detect even small, early-stage tumours within minutes.
By comparing the tissue composition of one breast with the other, the system is sensitive enough to detect anomalies less than one centimetre in diameter. A negative result could quickly rule out cancer, while a positive result would trigger referral for more expensive tests using mammography or magnetic resonance imaging. In addition to reducing patient wait times and enabling earlier diagnosis, the device would eliminate radiation exposure, improve patient comfort and work on particularly dense breasts, a problem with mammograms. However, this technology will take a while to come to India as it is still at the nascent stage.
In the end, people have to realise that while the Coronavirus is a serious pandemic, they must not neglect their overall health, compromise on regular check-ups and doctor consultations or delay cancer treatment. However, all hospital visits must be undertaken with complete precautionary measures that are the new normal now.
(The writer is head, Department of Surgical Oncology, Manipal Hospitals, Dwarka)
US President Donald Trump has a point about Indian air quality and it is no laughing matter
People living in north India, particularly Delhi, under truly choking conditions would not really disagree with US President Donald Trump’s statement about India’s air being filthy. They should hope that this ultimate repudiation of our ambient quality and pollution in a US presidential debate might force the Central and State Governments to finally do something about it. Like it or not, Delhi’s air knocks years off the lives of its citizens and if farmers want the sympathy of the urban populace and the media over the new Acts, they will not get it till they stop burning stubble that leaves a haze and blocks sunlight every morning. The persistently poor air quality in India is now officially a global joke and our politicians’ reluctance to deal with the issue holistically because they do not want to irritate their agricultural votebank is an even bigger one. Hundreds of crores have been raised as green cess in Delhi; why is this money not being used to subsidise agricultural machinery for farmers in North India so that they can get rid of crop waste in an eco-friendly manner? The lives of our children are being ruined by chronic pulmonary conditions such as asthma and politicians are trying to blame everything under the sun but the most obvious cause. They can’t even attack the automotive industry anymore as it has moved to very low emission BS-6 vehicles now. There could soon be medical evidence to prove a direct connection between high levels of pollution and the spread of the Covid-19 pandemic. Say what you will about Donald Trump, he does speak about a lot of things without filtering them through political doublespeak. He was proven right about China and he is absolutely right about Indian air quality.
Prime Minister Narendra Modi has the political capital to do something about this and he must because inaction on this front will taint his legacy. The right to clean air should be a given and like it or not, this impacts the poor and underprivileged whom Modi and even Chief Minister Arvind Kejriwal claim to stand for the most. The chattering classes with access to air purifiers can afford to live with it. So whether Trump remains in office or the US gets a 46th President, the time for Indian politicians to act is now.
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