It was a cool pleasant morning in November 2020. As I was striding across the gravel-studded foot-way leading to the hospital, I had a strange feeling of newness; everything around me was as if new, the big porch leading to the hospital entrance, the temple on my right, the scantily parked cars in vicinity and even the resident doctor who was accompanying me. Everything was as if new. It was quite natural, I felt, after all, it was after a long break of seven months I was joining back on my work in the hospital. Full seven months away from the hospital. Though busy with my private outpatients, a hospital round was always the cream of my activity. I was forced to keep away from it. The reason: Corona-phobia. I was 65. Hospital management had advised me to keep away from the hospital in good faith. I could see the well-meaning logic behind this. I belonged to a high-risk group for corona disease, given my age; and the hospital did not feel like taking the risk. Walking back, I explained to my resident doctor the logic behind this advice and also my prompt and whole-hearted compliance in the matter. “After all, even if one of the senior consultants were to suffer seriously due to covid, the negative impact on the staff would be incalculable, it is prudent for the hospital to advise me that way” Little did I know then, it was to be my own future after next few months, a patient of severe covid pneumonitis, rapidly worsening from oxygen therapy to full-blown ventilation therapy in a matter of two days. This happened five months after. It was when the so-called second wave of corona pandemic gripped the entire city in an unexpected ferocity. In a way my keeping away from the hospital during those seven months, my use of masks for legal satisfaction were all proven useless. Corona did catch me as per its will and whim.
In the wee hours of the morning, on the auspicious day of Gudhi Padwa, when there were plans for a family celebration, it all started. A few days of sore throat, some fever, many loose motions, and my oxygen saturation plummeted to 90 and below. A grave sign. Suchita, my wife collected the necessary utilities and I was rushed to Deenanath Hospital. My memory of the events that followed is patchy. I remember being emotional at times. Our minds are badly inclined to negativity. There was a sense of impending death that engulfed my existence. I went too far, felt sorry to be destined to have so little longevity in our family. I was so careful about my health otherwise. No indulgence. Good time management. Extremely regular lifestyle, comfortable sleep pattern. Even as a resident doctor in my younger age, I would sleep for good four hours in the evening before I would join my night duty, it was an attempt to prevent sleep deprivation. I had even refused a role in a drama in my college days, for the sole reason that it demanded smoking! Looking back after so many years, it looks so much juvenile, puritan. I have been taking regular exercise to my capacity. Though not a health freak in the current sense, I was careful enough not to damage my health in any known way. My primary contention has always been that body and health are the greatest gifts that nature has endowed us with and we have to preserve them since they are our only means to enjoying our lives. Even though I am a physician, dealing with medicines, my own consumption of medicines has been miniscule. No unnecessary medicines. Maybe that, I had some extra pride in my health management, an arrogance perhaps; which took a massive beating as my condition worsened. I took a faint look at Suchita, remembered my daughters, granddaughters, all my family members as I was wheeled rapidly in ICU. Things happen so fast that you hardly get any time to express yourself when you depart. I was grieved, felt annoyed at the course of events.
While in the ICU the true story began unfolding. The oxygen saturation would not respond to nasal prong oxygenation, mask breathing, or even high flow nasal oxygenation. I could see the worry and anxiety written large on the faces of my colleagues. Outwardly they were encouraging me, trying to keep my morale intact. Even in that state, I could sense that the optimism they were showering on me was more out of their love than the reality. Later on, a kind of physical and mental dumbness started pervading. I became totally negative to the prospect of any management. I felt like leaving all this and going back home. I was never a part of management in any serious covid patient so far. I was on a self-proclaimed leave. But I had my own reservations about many aspects of covid management plan all over. I had a feeling that steroids avoided as much a possible or should be used for a very limited time if at all, that Remdesivir need not be used as much as is possible on account of its poor efficacy, the only point in its favour being that it was generally nontoxic. I was strongly against using immunosuppressants for covid. The idea behind this was relatively simple. Whenever a pathogenic organism enters the human body, it is identified antigenically in as short a time as is possible. Pending this identification, multiple antibodies are produced in an attempt to contain it. This is called an Anamnestic Reaction, and it happens through the activation of so-called memory cells in the blood which are supposed to carry the memory of the entire lifetime exposure to various antigens. Since the current virus is a novel one, many of us may not have any memory of a similar virus in our memory cells. This leads to a massive outpouring of various non-specific antibodies, complements, cytokines in the blood, leading to what we call as Cytokine Storm. Maybe that the storm itself causes harm (the current treatment uses this hypothesis), but it is also possible that the same mechanism is the way to develop antibodies. In the latter situation, we could be harming by suppressing the natural immunological process in the body. All this logic in the background and with that the prospect of having to consume all these medicines in due course must be at the back of my resistance. Coupled with all this, statistics were showing very high mortality in ventilated patients. I am sure our doctors must have found a tough customer to buy in me! All this flashed for few seconds in my mind and then followed a complete silence.
I do not have any memory of what followed. It seems they had intubated me and put me on ventilation which continued for ten days or so. For me, it was all silence and dreams. The dreams were all bizarre, irrelevant, and irritating.
In one of my dreams, I remember lying flat on the floor listening to some vague music of all sorts. The room that I occupied was decorated with many odd shapes, so was the floor. The colour of everything was dull blue-grey. Many patients were lying in all directions across the floor listening to the same repetitive music. I cannot say whether I should call it music at all and it lasted for eternity. The instructor came from nowhere finally to stop it all and asked me how did I find it. I was already feeling lulled into silence, too fatigued with boredom, had no strength to answer the question. However, there arose a distinct question in my mind even then in that state – How will this cure my covid?
The daily sponging with warm wipes must have created a deep impact on me. I felt filthy, desperate, dependent, helpless against it. There were many dream sequences involving sponging. They gave me sponging at all places, in the room, in a tunnel, on an open road, in the evening twilight, early dark hours of the morning. They were never tired of it, though I felt loathe to have it. I felt shy of getting nursed, their unending sympathy drove me mad.
There were hallucinations of various sorts. The ICU itself must be having a lot many alerts, alarms. Superadded to that I used to hear low-tune music mingled with that. The music continued all through. Occasionally in the midnight everything as if would get angry, its pitch rose. the tempo of the music got accelerated, the rhythm became fast and with that my bed, my room joined in the chorus. Everything in the room started oscillating to the tune of music. This would last for minutes.
I could smell some faint sweetish smell all around, could see tiny creatures akin to spiders descending in groups along the walls. They shone brightly at night, dangling on loose threads right from the roof to the middle of the room in blues, violets, and reds.
The combined effect of all this made me paranoid. I lost my faith in the people who were nursing me so well. I doubted their intentions, had a feeling that I was getting drugged, mesmerized. I would repeatedly request someone unknown to rid me of this situation but to no avail.
Superadded to all this there was the phenomenon of what we call ‘deja vu’. I had a constant feeling of having had similar experiences before. This disturbed me further. The question that why am I being subjected to this agony again and again became a matter of desperation to me.
Sometime during this phase, my sedation must have been decreased or stopped, ventilatory support removed, I was probably put on only an endotracheal tube with oxygen. Medically these were signs of recovery. But now a different set of problems emerged. Oblivious of all that had happened in between, but conscious of the current surroundings only in a vague way, I could not explain my current plight. My medical knowledge as if had already deserted me. I could not comprehend the endotracheal tube going down my mouth, was surprised at my inability to talk or even phonate. This was an expected disability due to the tube inserted in my windpipe. I found that both my hands were heavily tied. Further, there was so much weakness, I could not even move my head sidewise. The tongue was so dry, the entire oral mucosa was dry, thick like a parchment. There were severe restrictions on my water intake. It was difficult to bear those with my mouth dry as parchment. Unable to vocalize, to register any dissent through limbs since they too were tied, I was left with no option but to lie helpless and philosophize. When you are completely helpless, philosophy is the need of time. In the good old days, I remember, I had seen an old lady in a similar plight. Admitted sometime during the night for rowdy behaviour, she was tied to her bed by night sisters. This was to restrain her from damaging herself. An act done in good faith. But at present when seen by me it seemed the lady was fully conscious, no longer needing those restraints. I found it funny, funny just because it was not me who was restrained. In a lighter tone, I asked, “Aaji, what did you do in the night so that they had to tie you?” Her philosophical reply was touching. “It must have been something that I did some time in the past or may even be in my past life. Otherwise, why would these girls (meaning sisters) treat me that way? It has to be my Karma. “I felt amused. I ordered the removal of restraints immediately and made her comfortable. It was a kind of funny justice to find myself in a similar position years later. Though it was not unjustified, the agony of restraint was just as the same for me!
For the next few days, it was the phase of hallucinations. I had hallucinations of all sorts. They were auditory, consisting of popular cinema music of the old generation. This music gave me a constant accompaniment all through. The ICU staff had given me special permission to play music on my device as per my choice. After an initial phase of recreation, it became a matter of hallucinations to me, the music just won’t stop. The songs would continue unabated one after one in an interminable way. Even whatever dialogue the sisters would have among themselves became music to my ears. I would see some unknown paintings the moment I closed my eyes. Wall hangings showing old mugal badshahs, their darbars. I could see some computer screens, tried to perform financial transactions on these imaginary screens. It became so repetitive that I got bored of those. The sleep mainly consisted of vertiginous hallucinations, the entire surrounding around me vibrating rhythmically, rotating, lifting me to unknown heights. There was a confusion of thought, I could hear some religious chants. I could see the books which I had read in the past, all mutilated, their pages lying apart. All this together gave me a feeling of extreme depression and negativity which was wordless.
After a duration of four to five days, these issues were resolved. I started getting reasonable sleep, increasing periods of wakefulness. But all the same, it was not the end of the matter. Now weakness took its toll. It was a kind of weakness never experienced before. There was extreme inertia to activity. I could see the call bell dangling just by the side of the bed, I felt the need to call for assistance, but there would be no drive to lift the hand and press the bell to call for help. Scores of minutes to half an hour could easily be spent in an indecisive state whether to press the call bell on not. Most of the activities had to be supported, even turning to one side called for a great effort. The mattresses in ICU and room were indeed great, they supported the body very well. Their feel was good, just hard enough to support. They were easy to clean. But somehow they prohibited me from doing any movement on my own. Turning in bed, shifting in bed, sitting in bed- every time I had to call for assistance. This reduced my stamina further adding greatly to the need for physiotherapy. The beds were electrically operated. Convenient though, they completely drove away my initiative to move on my own.
There must have been some problem with my visual cognition, I found it difficult to recognise and identify faces. Few of my friends, colleagues were regular visitors for me. With a mask on their face, they had to introduce themselves every time they met me, and even after that occasionally I had doubts about their genuineness. My paranoid ideation doubted everything. Both the eyes would be running constantly, tears trickling down over cheeks. It would give an impression that I was crying incessantly. I had no specs with me. Looking at the objects with watery eyes, with no specs- I felt like a fool at times. I found it difficult to read the wall clock, had to keep on looking at it in a vain way trying to decide what time of day or night it could be! I must have irritated the sisters attending me, due to my repetitive inquiries about timing. Initially, they responded sympathetically but as the query became too repetitive, they started bluffing it, adding to more confusion. At any time, my mind had to fight with three timings, one was my mental clock, the actual timing as shown in the wall clock, and the timing as bluffed by sisters. In painful situations such as these, our mental clock probably runs faster than the actual one. There must be a desire to run through the calamity at a faster pace so that it ends sooner.
Once off the ventilator and after the endotracheal tube was removed, reasonably stable in what could be called ‘consciousness’, my sole aim was to go home. I wanted the I/V line and the arterial line to be removed, the urinary catheter had to go. It must have been a matter of great puzzle for all my treating colleagues listening to my repeated frenzied requests to be sent home. Did I fail to understand the gravity of the situation that I was in? Yes, I did.
I had already started dreaming about running away from the hospital. It would be easy, just sneak out of the room, reach the ground floor, call an auto and reach home. I could always ring up the hospital after reaching home, discharge process, bill payment could be managed online. I felt it was so easy. I knew, my colleagues loved me, had done their best in treating me; but in their affection for me they had gone blind to the recovery I had made, they were overdoing their job by prolonging my stay, I felt. My daughters one of whom had travelled all the way from the UK with her husband and my granddaughter just to meet me were waiting somewhere at home. I had to reach home at the earliest. I pressed the bell, the sister attending me reached the side of my bed. I requested her to remove my catheter.
“I plan to go home today”, I declared. She must have been aghast. Knowing my position, my seniority in the hospital, she could not counter my funniest demand.
“Sir, it’s three o’clock in the morning; I shall remove it after 6 in the morning, Ok?” She placated me somehow, but I implored her not to forget this, “I have to meet my daughters, I don’t have much time with me. My daughter from the UK cannot wait for long,” I said.
During my clinical practice of the last four decades, I have always considered myself to be an academically efficient, compassionate doctor. I claim to have a lot of empathy for my patients, but in my younger days, working as a resident doctor it was not so; I used to read a lot of textbooks, discuss a lot with my teachers, colleagues which gave me a lot of confidence in my academics and also inflated my ego, but there was no training for the humane aspect of clinical medicine. During my tenure as a houseman, I had a young patient in his twenties admitted directly from the casualty, with a casualty doctor’s note saying that he was deep comatose. With whatever limited expertise I had then, I could see that it was not so. He was not unconscious; He was drugged, had probably consumed Charas. Few younger undergraduate lady students were observing all this. The lad under consideration must have been some religious trainee, scantily clad with a bhagavi dhoti. I wanted to make the event dramatic and prove my clinical prowess to the girls around me. In a swift motion, I pulled at the dhoti that he wore. Stunned at the activity and seeing so many girls around, our patient took a clue, jumped off the bed, rescued himself running across the ward in a half-naked state, holding onto his dhoti awkwardly. It was such a hilarious event for us all, a claimed unconscious person running out of ward on his own in a few minutes, quite impressionable. Looking back after so many years I can see the cruelty in my act. There could be a few more such obvious instances to quote from my practice. But I feel I have matured and changed over the years. But is this change sufficient enough? I can see my irritation when a patient asks me the same questions repetitively despite being adequately explained by me. I do get annoyed when he rejects my scientific advice. My pride still hurts a bit when he takes an independent second opinion from a doctor. Not only that, I feel insulted even if a patient gets a few more tests done than I have advised him to do. There are so many tiny instances where my ego about my compassion stands as a hindrance in understanding my patient’s viewpoint. If as an experienced doctor, my reaction to my illness could plummet to levels as I described above, I must learn to grant many more concessions to my patients.
Amongst my friends, colleagues, and my students I am generally known to have different views about medicine than the common perspective held by the fraternity e.g., my perspective about common diseases like hypertension, diabetes, ischaemic heart disease, chronic kidney disease is often different than most of the others’. The recent corona pandemic was no exception to this. Right from the beginning, I had doubts about the way this disease was interpreted, about the way its control measures were suggested, and how it was medically managed. I had my reservations about vaccination as well. Though I never promoted my views amongst my patients, never encouraged them to violate the government regulations from time to time, I had always voiced my different opinions in various groups. I was fairly aware that fighting against corona was like fighting a war and all of us were like warriors in the war. A warrior is supposed only to obey, not to think independently. That was exactly what I was doing and advising my patients. But there were occasions when I would discuss the different views that I held with some of them and it had a soothing effect on most of them.
The masks theoretically may reduce the throw of respiratory droplets thereby reducing their transmission, however for this they must have defined filtering characteristics. A situation similar to this was seen in the influenza pandemic due to the H1N1 virus some ten years ago. It had apparently a similar mode of transmission. However, it was soon found that any ordinary mask lesser than the advanced N95 one, was ineffective for prevention of transmission, and hence, the insistence on using masks was reduced, eventually so much so that no one even talked of using masks in social surroundings then. However, when the Covid 19 virus emerged 10 years later, the recommendation for masks emerged so strongly, that not wearing them was treated as defiance of law and was punishable legally. I am not aware of any research strongly proving the utility of masks in such a great way, having been conducted anywhere in the last decade. The additional issue with masks is the way they are used. Wearing a mask by a surgeon during surgery is an altogether different issue since it is used for a relatively shorter period by a surgeon who understands the significance of this activity too well. The situation changes dramatically when it is advised universally for one and all, regardless of their educational and understanding ability, and that too when it is advised for 24 hours daily all through for an undefined period. It simply becomes a plaything for most. They touch their masks inside out, fold and keep them where ever they like, be it in their pockets, purses; take them down exactly when they want to talk, cough or sneeze. There are no ways to check if they are changing those after every use, it is also a matter of dispute whether it is correct to wash and reuse those. The legal insistence on using the masks has turned into something like a religious ritual, the utility of which has to go unchallenged and if you do so, you are likely to be treated as antisocial.
It is also possible that a mask made from the wrong material and handled in the wrong way could actually help the transmission of the corona. Electrostatic forces might in fact attract the droplet nuclei on it and help to transmit those to the user’s nose. A mask over the nose is a definite source of irritation, leading to handling, readjusting of the mask and thus, leading to enhanced transmission.
Even as on today, 18 months after the pandemic, we are not sure how the coronavirus is actually transmitted, whether by droplet nuclei for which masks may be partially deterrent; whether it is through surface transmission in which case masks could be useless to detrimental or whether through airborne transmission as aerosols in which case one would need only N95 masks. In this situation, a vehement approach towards mask use seems unjustified.
Another disadvantage of a mask is that it has become a marker for corona phobia all over the world. None of the authorities knows enough to advise when to do away with it. Use it if you are normal, continue using it even if you suffer from covid infection and get cured of it, use it even after vaccination, use it even if you test negative or positive for the virus. At the time of writing this, it seems masks are being considered redundant in part of Europe, the USA, Australia. But with a theoretical risk of more waves of Coronavirus still in the air, it is difficult to predict how long this contention would prevail.
Universal social distancing and quarantine of cases is a similar trap. Theoretically, if the society completely closes itself with no interpersonal interaction of any sort; the pandemic would abate instantly, but the golden question is for how long can we do so successfully. There is no proof that the virus will exterminate itself after a defined period, so that social distancing during that phase would stop the viral spread forever, in fact, as history reveals such viruses remain in the society forever, causing sporadic infection. Social distancing in this context, will not ‘Break the Chain’, as is the motto of the government, but will only prolong the chain as it has already done. The so-called second wave seen all over is actually not a second wave but a prolonged first wave as a result of effective social distancing last year. The more effective the social distancing, the more are the chances of recurrence of newer waves. Additionally, in a country as populous as India, it is impossible even to dream of effective social distancing for prolonged times.
Additionally, social distancing leads to a significant economic loss. There is no way to compare economic loss to that due to the loss of life and to decide which one of the two was more grievous, loss of life would always score over the economic one given the emotional overlay attached to it. But now at the end of the 18 months of recurrent lockdown somewhere, most of the governments have started feeling the gravity of economic losses, they are getting wary of prolonging the lockdowns further & further. Even there are increasing social outbursts against such unplanned and protracted lockdown in the society at large.
The emotional and social losses encountered due to lockdowns and quarantine are also no less. The educational losses of children and students, lack of hands-on training of the students, lack of social exposure, family relationship-related discords too are a part of the great devastation caused by lockdown therapy. The entire generation of small young children and teenagers has suffered incalculable harm in lockdowns.
What hurts more, when one comes to think of the fact that, at no stage, it has been proven that lockdowns reduce the total mortality due to the pandemic and still they continue to be promoted so strongly. In the absence of any curative treatment for corona, a lockdown will only lead to a spread of mortality over a longer duration, patients who have an intrinsic inability to mount effective immunity against the disease are destined to succumb to it at some time or other. But this matter is very difficult to prove. If we look at the scenario in India, at the end of 18 months of the pandemic with varying levels of lockdowns, we are actually worse off in all the parameters of the pandemic, the number of cases going up, deaths still continuing at a high rate, economic breakdown at its worst, fear complex related to the disease at an all-time high. Still, we continue to praise ourselves for our achievement through our efforts. Nobody wants to look back and evaluate the outcomes. In the absence of such objective evaluation, the masks, and social distancing continue to be considered as the only sure means to prevent the spread of disease and remain as the ultimate truth. The objectivity is lost so much that even the failure of these means is not seen as the failure of our approach but as a failure of people in implementing it. We blamed ourselves for this failure. This is an unprovable blame game that all of us are playing. If our efforts during the last 18 months were really in the proper direction, we should have seen the end of the pandemic long back and should have been free and happy by now but the case is exactly the opposite of it, we are in fact far too worse, going through a so-called second wave of far too worse magnitude and apprehensive of a third wave of the disease! We are trying to make our own lives more and more difficult through our preventive efforts!
Amongst all the modes of prevention, vaccination appears to be the most logical step. Any pandemic would finally get controlled only after herd immunity is developed. The way to the development of herd immunity is through natural infection (which is very fast in a pandemic but fraught with the risk of disease and death) or through immunisation. There have been certain major technological achievements during the vaccine development for covid. The new mRNA technology for vaccine development can be mentioned as the most prominent amongst those. It has paved way for the rapid development of vaccines for the future. Also, the overall speed at which all the other vaccines were developed is commendable. At the back of my mind, there were two tiny doubts regarding these vaccines. These were the first vaccines developed and deployed on such a universal large scale. They were also developed in a hurry, were pushed in the market using the provision of emergency use authorisation. In such situations, the possible long-term side effects are likely to be underrepresented. Certain degenerative, inflammatory neurological complications could develop even two months after vaccination. Given the massive global immunisation drive for the corona vaccine, even a rare complication could lead to unacceptable morbidity in society since we aim to immunise the entire humanity at one go in a short time, an experiment such as this was never undertaken so far.
One more caveat regarding vaccine has scarcely been thought over. The mortality due to covid is of 3 types. One; due to covid itself, the so-called mortality directly related to the infection, two; that due to severe comorbidities, where corona may have only contributed remotely, and three; that due to the treatment of corona. This is mortality due to immune suppression leading to superinfection, blood clotting disorder, etc. As of now, there is no definite curative treatment for corona infection. Thus, the true mortality due to corona in a way is not modifiable. This mortality is probably due to some problem in the immunological system of that individual, who is unable to build up the required immunological response against the virus. If you extrapolate this to immunisation, it is highly doubtful that these persons would develop any strong protective immunity even after vaccination. Thus, it is possible that the true mortality due to coronavirus would still continue to occur despite vaccination. What would probably reduce is that mortality where the role of the corona is merely contributory. It would also reduce the mortality due to treatment-related complications since it would help to prevent such cases from complicating thereby reducing the unnecessary treatment load.
Personally, I wanted to wait for a while and check for its safety before getting vaccinated myself. And as the luck would have it, I got infected before I took the decision either way. A few of my personal friends must have seen this as my whim in not taking the vaccine. It was never the case. In fact, to all my patients who sought my advice in the matter, I had suggested that they go ahead and get vaccinated. ’The vaccine is reasonably effective and reasonably safe. One should go ahead and have it’, was my standard advice to all of them. There were a few who themselves had a different opinion in the matter and did not want to take it. They would insist on having my opinion regarding this view. I would reassure them by saying that even if they do not get it up front, they would eventually be getting the benefit of vaccination when most of the society get vaccinated and/or infected. This protection would indirectly be related to herd immunity and not individual specific.
I was also of the opinion that the overall efficacy in building up herd immunity through vaccination is going to be poor. The natural spread and the speed of this spread were likely to be so great that even with the best resources in western countries, it would be very difficult to achieve significant immunisation before the natural course of the infection had run its course in the society. Considered in this way, I felt that the entire effort and research in the development and administration of vaccines were partly redundant. Despite this, I felt that the vaccination was still one of the better ways of preventing the infection, especially when compared to masks and social distancing.
They were all sitting around me, our chief intensivist, all his competent colleagues, residents, anaesthetists, chest physicians. Some of the residents were my students. It was some time after I was shifted to ICU for a drop in oxygen saturation. I was put on high-flow nasal oxygen, but the saturation would not come up. Mad with anxiety and afraid that I was to receive the same treatment which I despised so thoroughly, I remember myself making aggressive irrational comments.
With oxygen saturation plummeting I could see that I was heading for ventilatory support. It was known to me to be an unavoidable devil. Despite all the heavy mortality that went with it, it had to be offered to a class of patients who had no other means of survival otherwise. I could see that I was one of those.
“Don’t start me on steroids, immunosuppressants. No ventilatory support. Don’t resuscitate me if my heart arrests”, my demands became too radical for anyone amongst them to digest. They must have been stunned into disbelief. The ambiance in the ICU was actually not that bad. It was exactly the other way round. There were beautiful pictures painted all over the wall, and ceiling of the ICU. It was our paediatric ICU. As a treating physician, I had visited this ICU many times and had praised the interior of the ICU so often. It must be so pleasing for the children, I felt. But today all of it was dark to me. I was totally oblivious of their beauty. They looked so irrational, meaningless. Nobody listened to me. Before I could resist further, I must have been sedated and intubated.
“What kind of prescription is this? An antibiotic like azithromycin, steroids, a tablet of Ivermectin, HCQS, an antacid, a tablet of vitamin C, D, B complex, an antifibrotic agent, colchicine, some probiotic. All this for a minor covid? Some 20 tablets in a row, of which none has a specific purpose?” I was almost shouting.
This dialogue must have happened a few weeks ago when I read a prescription given by someone to a minor covid patient. My resident doctor had to take my outburst with equanimity. It was nothing unusual for him. That is how the covid practice was going on everywhere.
When I was studying gynaecology, one of our senior consultants had taught us the concept of ‘Careful negligence and watchful expectancy’ while managing many obstetric complications. It meant that an obstetrician must learn to be patient, nature most often would do things correctly to the patient’s advantage without any intervention. Four decades down the line, I still remember his words. As human beings, we must learn to have patience. Sitting apparently idle, doing nothing, and expecting that something better would happen is a difficult proposition. As doctors, we feel that we must act; not only that, our patients too expect us to act. If the doctor does not act, then even patients themselves can act. There are so many advisers around them. Friends, colleagues, WhatsApp, Google, TV channels. Knowledge is so handy nowadays! In many cases of mild to moderate covid close monitoring of oxygen saturation is all that is needed. Many other parameters such as IL 6 levels, D Dimer assays, CT thorax, CRP, etc. do not add to any change in the line of management of a mild corona infection. A single batch of laboratory tests for assessment of covid infection could as well cost to the tune of 5000 to 10000 rupees. Such test batteries are often repeated periodically, adding only to the cost of management with no great value addition. The treatment logic too is just as gun-shot, trying to cover everything from bacterial infection to inflammation, from fungal infection to immunity booster, from nutritional supplements to antiviral agents. A multi-drug approach such as this can lead to drug interactions, drug-related adverse events, immunity suppression, superinfection with other organisms complicating the clinical scenario. It can be difficult to separate covid related complications from drug-related side effects.
“My dear, do you know what are the ways how a patient can recover from his illness?” I continued with my aggressive encounter with my resident. He knew the best way for him was to keep silent on such occasions. He just continued looking at me as if nonchalantly. “They can recover due to treatment; they can recover independently of our treatment and to our great luck they can do so despite our misdirected treatment. Our aim should be to see that we treat them in a way that we give them only the exact curative treatment and nothing more. This is a difficult objective oftentimes, but we should at least try to be neutral to their natural recovery, seeing that we do not cause impediment in their process of natural recovery, neither do we add to the already existent problem through our management. Gun-shot management like that can lead to a situation that the patients have to recover despite our treatment. In case of such a recovery, we may erroneously claim a victory, since what matters for the patient is only his recovery, he is not interested in the mechanism, but the real skill of a doctor lies in finding the difference in these patterns of recovery and monitor his performance as a doctor accordingly. Will you be good enough to be able to do that?” I had said.
Back in the ICU, nobody was in a mood to listen to my arguments; they knew they had to take their decisions independently without considering my jargon. They must have chosen to sedate me. I was thrown into the abyss of deep unconsciousness; the course of management did follow the protocol defined by the hospital. Ten long days later, apparently, my condition improved and I opened my eyes to reality. It seemed as if I had survived It all.
Covid has proven itself to be a great challenge to humanity. This was a challenge not only restricted to human immunity, in fact, the immunological challenge could be the least of the lot, it was a challenge to human psychology, economy, philosophy, morality. Along with these, our social systems, social values too were put to test. It tested our scientific capabilities. It exposed so many vulnerable points in all of us. Immunologically speaking, covid mortality is considered to be the result of immunological hyperreactivity in an individual. Simply put, the corona itself may not be as lethal as is the unwarranted immunological reaction to it. Whether this is an ultimate truth in its pathogenesis is a matter that could be debated. But when we consider its effects on all the non-medical aspects of humanity, we certainly can see our overreaction to corona causing more damage than the virus itself. If we consider the pathology of many such diseases as autoimmune, thereby meaning that it is our immunity working against our interest, this logic is equally applicable to other fields in human life. There has been overreaction everywhere. It can be called autoimmunity of a different nature.
We as humans consider ourselves to be a special species. We take pride in our so-called intelligence. We want to analyse life around us. We want to anticipate problems. We feel that it is our sole responsibility to solve those problems. With the advancement of technology, human arrogance has grown even further. We have started looking at technology as the only thing to be sought after in life. Technology is intelligence for us, it has replaced philosophy, it has been the source of all our material happiness. We have reached a level of arrogance, where we feel we can destroy nature, we can win the natural processes, and also, we can ‘save’ nature. How bold to think that it is within our means and also our prerogative to save nature! Nature has as if become subsidiary to human intentions. There has been a long-cherished myth that in the process of evolution human beings are the last step in the ladder, most evolved amongst the rest of the species. I remember a very poignant statement by someone. ‘The only proof that the human beings are the best amongst all the species is that none of them have challenged it so far!’, he said. The real answer behind this contention going unchallenged so far could be that none of these species are aware that such competition for superiority could exist and also are not interested in it. The famous Marathi author, G A Kulkarni has made a remarkable observation in one of his parables. Someone in one of his stories claimed that human beings are the most evolved because they can discuss philosophy, which no other species can. He had a ready answer to this, this is only because all the rest of the species have found their philosophy, which humans have yet to, he said!
If we want to study how corona has exposed us, we have to see how we have destroyed ourselves under the threat of corona. It was systematic destruction under the garb of self-protection. All our efforts can be seen as an overreaction, a kind of autoimmune reaction. We killed ourselves economically, by overreacting to the threat of the disease, putting social distancing, quarantine as the only means to prevent the spread of the disease, and caused such irreparable damage to all our economy, that it would take us very long to raise ourselves out of it. Deaths due to covid are easier to calculate, the deaths due to economic losses may not be so easy to determine. There are also situations in life where the economic factors could be so damaging that death would be the preferred mode of exit! There are no means to calculate this.
The fear of death due to corona and promotion of social distancing as the sole effective means to keep away from it, lead to altered behaviour of everyone around us. It would be wrong to say that people became inhuman, started despising each other, no it was not so, they were as caring as before but their relationships were overpowered by fear of imminent death; there was a certain element of aloofness that pervaded their relationships. It became a common practice to avoid even eye-to-eye contact with a suspected covid, doors would be closed on the face of a covid patient with fear that corona may enter through the open door. There is a complex of apartheid sitting in the mind of all of us. It shows itself as colour discrimination in some societies, as caste discrimination in some societies. Even gender discrimination too is a part of it. After years of fight, we have tried to eliminate it from our minds with only partial success. Corona opened a new way to the same apartheid. Those who tested positive were considered different and to be avoided. I call this a ‘Corona religion’. Just as some various religious customs and rituals go on in a religion without any rational justification, corona rituals were varying from home to home, from communities to communities, and from nations to nations. In Indian cities, the poor housemaids were the first victims of this. They were prevented altogether from entering houses in the initial phases of the pandemic, forced to wear masks, gowns when finally, they were allowed inside the house. Some were allowed to enter only through specific doors in the house, allowed entries only in limited rooms in the house. In some families, the gowns and masks worn by them were stored separately to be washed by the lady of the house after disinfection. The maids were disallowed to use lifts. One of my patients got a fever suggestive of the corona. When I advised him to get tested, he came out with a very prompt response. “It just can’t be corona, Doc, ever since the last few months I have been taking bath thrice daily, with all my clothes on my body.” That sounded like a very fresh idea to me. Taking bath thrice a day with your full suit on as prevention for corona! Many took to wearing hand gloves even during day-to-day activities. Social distancing also had many variations. It was advised even amongst spouses when one of them tested positive. The phase of transmission starts much earlier than the symptomatic disease, and hence, the spouse of a case who has been staying together with him/her has already had a transmission. Thus, both of them should be regarded as infected and treated accordingly. This is the custom followed in the UK, but not approved in India. Here we talk of wearing masks even at home! The public gardens were opened with a lot of reluctance for limited hours in the day, implying that in a limited period corona transmission would be lesser. Masks were mandatory while walking in gardens or open spaces implying erroneously that the coronavirus could jump across individuals even during walking. Curfews were enforced, restrictions imposed on the number of persons gathering together again implying that the virus transmission would not occur if persons gathered in numbers below a specified number. This number too varied from place to place from time to time and from occasion to occasion. Shops were allowed to open only in a limited number of hours. This encouraged crowding in shops. There would be numerous such instances if one wants to enumerate.
There is one more aspect that may have some important contribution to the spread and pathogenesis of the disease. If as proposed earlier, the social distancing and masking do lead to a mere prolongation of the pandemic, there is a likely fall out of this prolongation and it would be far more dangerous. A prolongation of the pandemic would mean that the virus would stay for a longer period in the society, a longer duration would imply a longer time to multiply and mutate. Thus, these so-called preventive measures may in the long run promote the development of a greater number of mutants occasionally adding to the virulence of the organism. Is it possible that the numerous variants of coronavirus seen in the last few months are the result of the prolongation of the epidemic due to our control measures?
Finally, I would like to add a word about science and research about corona. The contribution made by science in the analysis of corona has been commendable. The rapidity with which the virus was identified, its structure defined, the antigenic spike protein was located, the rapidity with which the vaccines were developed, all this is mammoth progress by science. But along with this, has it helped the spread of the disease until now? Has it alleyed the fear complex in the minds of people? Rapid analytical progress in science along with the strong media has been more efficient in the spread of fear. The newer mutants of viruses are identified rapidly, and the information about these is spread far and wide over the globe in no time. The net result is fear of yet another wave. The blood testing for corona antibodies was developed rapidly, leading to repeated analysis of antibodies in the corona patients. But alas, it was seen that the antibodies do not last for long, they tend to diminish in few weeks. The net result: Fear that the immunity due to disease may not last long! This coupled with newer resistant mutants would mean more sinister waves. Everyone was in a hurry to draw negative conclusions, with no time to wait and observe the events. As is expected, our current research is well organised, but there is absolutely no need that all this scientific progress to be made public immediately. I remember a time when I had to wait while my car was being serviced. Many engineers were looking after it. I could see so many errors in their judgment, so many times they were trying and failing in their attempt to fix the problem, I felt disappointed, started doubting their ability in handling the issue. Finally, they did it all successfully, but the online undeterred information was far from encouraging to me. Later I knew those car problems are always fixed only in this way, but all this happens in our absence, we only get to see the final result. If information flows to common people too rapidly, it can overwhelm the abilities of the common man to handle it, leading to phobia. Even as scientists they failed in showing maturity in interpreting various findings. Conclusions were drawn too fast and they were often negative in nature. This also generated fear in the minds of scientists themselves. The development of science without intellectual and emotional maturity to handle it leads to fear psychosis. Corona did it for us. After sex, fear is the most dominant emotion in human beings. It was fear that dictated our behaviour all the way.
I am also sure many amongst us may not agree with these observations of mine, would continue to follow these preventive practices undeterred. They would likely blame me for holding such views & blame my infection with such rebellious thoughts of mine. Thoughts such as these imply a kind of careless behaviour for them and this would amount to an invitation for infection! There was a strong forward on social media suggesting that if you do not wear a mask in life, you will finally wear it after death. I had a strong objection to this since I had a feeling that forwards such as these spread fear amongst the population and glorify masks beyond their utility. There is no such direct relationship between mask usage and prevention of corona mortality with that absolute certainty. Most of the sufferers of covid have been reasonable in following these protocols and still they have had it. Forwards such as this only show the irrationally strong views held by many in this matter. I do not agree with the absolute finality that is implied in these views. Though I disagree with these, neither do I have an absolute answer to corona and its pathology. The views proposed here are mere alternative possibilities based on logic, but there could be genuine reasons to doubt their veracity. We have seen on many occasions in the past, how nature can betray logic. It may so happen in this case too. But unless, such contrarian views are considered, discussed openly one cannot expect to reach the truth, if there is any.
I have been through such a serious illness due to covid, an experience that was so close to death. I know, I have to answer many questions though they may not be asked directly to me. People generally are sympathetic; they do not want to confront you with straightforward questions and hurt you. The question that is going to haunt me for quite some time now is whether I repent my thoughts after all this calamity? Would I like to change my views in any way? I used to have a lot of discussions about covid with my patients. It used to be a kind of stress reliever for them because I was not so dogmatic in my views, they used to feel less cramped with fear after listening to me. Some of them would go so far as to comment that it was ok for me to be complacent and fearless (as they would feel that I was,) since I was a doctor myself who knew better than most and also had a better immunity than the rest. That sounded funny. I made it a point to explain to them that it was not so at all. As an ordinary human being, I shared the same weaknesses as the rest of them. I was just the same worried about catching infection myself. Some soreness of throat, a sneeze or two here and there, some sense of feverishness would send the same alarms ringing in my mind all through the previous year as it would happen with all of them. I felt in fact so sorry when I realised that I had not internalised my thoughts in a way I expected myself to do. I was aware that unless one overcomes the fear of death, life cannot be enjoyed. But this was only a theory, had I overcome it myself? Most often our philosophy remains a matter to be enjoyed as a theory by a select few at select times. Not many of us are even inclined philosophically, some of them could even have an aversion to it. Those who are so inclined, consider themselves a special gifted lot, place themselves somewhere above others but their internal self is most often the same as that of the rest of us; fragile, timid, and mean. Most of the patients used to be in a denial mode, declining the fear of covid altogether. They used to hide behind arguments such as; “It is not my health that worries me, but I have my parents, grandchildren staying with me. I am worried chiefly for those.” The argument such as this gives an impression that, but for their relatives, they were altogether indifferent to their death! One of my patients said, he does not want to die of disease as horrid as covid, any other disease would do! Again, a kind of denial. The basic curse to human beings is a denial of a problem when it exists. Having a problem and further accepting it looks demeaning to them. That is exactly where I differed from the rest, I accepted that I had a problem and tried to resolve it rationally. The basic expected norm of behaviour was to be afraid beyond limits all right but deny it externally and try to resolve the anxiety through irrational activities. I differed from most of the rest in that I refused to hide my anxiety and also refused to be dominated by acts that I felt were irrational. Even that was too much for most!
Even if we accept that my suffering from a serious covid infection was a failure of some sort, it was an individual failure in my immune response. It was never a failure of the theory that I proposed, which said that some of the patients suffering from covid die because there is an immunological problem in them that prevented them from building up the requisite immunity. The variable clinical picture of covid was a reflection of the variable
immunological competence of individuals against the infection. This is especially so since there is no effective curative treatment to alter the natural course of the illness. This theory still persists. My suffering does not negate it.
There is one more question that I may have to answer myself. I have discussed enough of theory, many times antagonising the current views. Do I have to offer any alternative way of handling the pandemic? Would I suggest some different guidelines for handling a pandemic such as that?
I hope we are nearing the end of the corona pandemic in the city. There is an apprehension of the third wave around, but hopefully, it may not materialize. It could be time for us to draw some conclusions based on the pandemic as I see it.
The significance of testing for covid was overemphasized and wrongly emphasized in the minds of people. Testing is important for epidemiological purposes; it has little bearing on the management. With this idea clear in mind, the testing could have been done, but there was no need to make the statistics public and project it to common people. In the setting of a pandemic daily rise in the count of cases helps only to generate fright reaction in the minds of people.
Patience is the key in management. A doctor who is panicked in treating the disease is likely to overreact, overtreat leading to a different set of complications. Panic is pardonable in a patient but the same when seen in a doctor, amounts to professional incompetence. There is an attempt to reach conclusions especially the negative ones a bit too soon. You find some marginal benefit for one of the medicines, there is an immediate attempt to use those. You find a fast loss of antibody titre in cured patients, there is an immediate conclusion that the immunity is very short-lasting. We do not have the patience to see if the infections are really recurring. The moment a new virus strain is located, we send a panic reaction in anticipation of a new wave, more lethal, more infectious. In a rapidly evolving pandemic, many drugs are pushed in clinical management protocol through emergency use authorisation. This can prove to be a dangerous shortcut for their use. This facility should be used with extreme diligence only for such drugs which are found to have some extraordinary therapeutic benefit. The drugs that have shown only marginal utility are not the candidates for this. The potential for the adverse reaction is likely to be underestimated in such situations. The problems of profound immunosuppression, coagulopathies were the possible side effects of over usage of certain medicines. The financial impact due to the usage of such medicines too is devastating.
The research has to be undertaken, but the findings of such research must not be shared with the general population so soon, not even with the doctors working at ground level. The research would continue at its pace in the background and the results of such studies should be disclosed only after reaching a certain maturity. Early release of such findings adds to the panic and overreaction. The researchers themselves need to show extra restraint and need not feel forced to draw rapid conclusions in the face of calamity.
Oxygen therapy is the only game-changer treatment for covid. It has saved many lives. The entire focus on the management should have been on oxygen therapy at home. Rather than running after hospital beds, we could have arranged for home oxygen therapy for even moderately sick persons. A supply of oximeters at home along with a mobile app to document the oxygen saturation which could be monitored centrally would have helped us to avoid a mad rush for hospital beds and the hospital treatment could be offered only to serious unresponsive hypoxic patients. It would have avoided congestion in hospitals. Only those with a need for ventilators would have gone to hospitals.
Even for vaccination, we could have opted for single-dose immunisation for all. This would have reduced the administrative burden, would have given reasonable immunity to control the epidemic. We could have immunised twice as many persons. The need for a booster dose could have been proven and undertaken at a later date in select populations.
After almost three weeks in ICU and my treating doctors developed confidence and decided to shift me out to an ordinary room. That was a great decision. I felt many of my problems would settle favourably just by shifting to an ordinary room.
But the life outside the ICU was also not simple, it was all studded with problems. Problems of sleep, bowel movement, urination, weakness, giddiness, loss of taste. The dependence on others for all these activities was very disturbing. The loss of strength and weakness were so profound, I was taken aback to see my own thinned limbs. The daily chorus of physiotherapy, was like an unpleasant examination for me, showing my failure in all activities. I felt I was locked in my spastic muscles. Eating, mastication was a problem, the jaw would go in a spasm after taking the very first bite. I lost my enthusiasm for eating. Now my thought processes were more in line with the reality and as it did happen, my enthusiasm to go home waned. I started doubting my abilities to survive alone at home without the help of the support staff that was so helpful and so needed. On top of it there was a daunting worry of superinfection.
In the silence of an ordinary room with Suchita around me, slowly did I realise what a great impact I had created in minds of people who were connected to me. They were all my relatives, my friends, my patients. Some of them were only casual contacts and well-wishers. There was such a flurry of telephonic calls and questions regarding my health condition that my daughter had to keep busy the whole day answering them. Most of them prayed for me, prayed from their heart. My corona showed me how people silently love you. So many prayers were offered. For many, I was an atheist, a thorough non-believer. Praying for me in my difficult times seemed paradoxical to them, but they continued in their all-out efforts to try and save me. Personally, I am not an atheist, I am an agnostic. I fully believe in the limitations of human beings; I am aware that life around us is not only unknown but also unknowable. It is this unknowable that is God for them. I respect this God. Though I may not visualise God as most of them do, may not believe in their prayers as they do, but I do believe in the faith that forms the basis of their belief, I believe in the love that is in their hearts. My stay in the room gave me some time for introspection.
“Great, Sir! So, you have won the battle, the battle against corona. I knew it right through, was telling everyone around, Our Sir is a great warrior. He won’t take anything lying down. He has to win ultimately. You have such amazing strength, determination, ….” Somebody was praising me. I could see how sincere he was when he said so. But also, could see, how false he was. I have never considered myself a warrior against nature. There never was any question of winning anything in nature including nature itself. I have always seen myself as an inseparable part of nature, in a complete unification with it. The fact that I suffered from corona infection, that too such a severe one & that I came out of it was all nature’s choice. I had no choice in it. I cannot have any discredit for my sufferance nor can I call my recovery to be a victory for me. I have always been a firm believer of the fact that there never is any choice for anyone anytime in life. It may sound so brutal, we so much like to have a choice in life, so much do we feel that we have one. It is on this great pretence that life is built. Seeing the truth through this pretence is a great jolt, but as and if we understand it, life would be so simple, just happy floating with nature. The days when I was sedated heavily, the days when I was being ventilated supine and prone; are all gone out of my memory now. I am completely oblivious of those. What kind of life did I live then? Can we call it a life when there is no consciousness? It was an unconscious life without flaws like ego, pain, happiness, ambition, etc. Can there be a flawless consciousness even otherwise in a normal individual?
The time for my discharge was to arrive in some days. With difficulty, I had to ready myself to take a dive in the real world, known so well to me until my admission and now the same world that looked so unfriendly and challenging. Sitting in a wheelchair I bid my final adieu to the sisters and the ward boys around me. They were happy to see me go home. I was too grateful to all of them, all the doctors, sisters, ward boys. I could see that the entire hospital staff was as if united in their objective to rescue me out of the situation and had done it so well. A mere look of gratitude, how-so-ever genuine and sincere it may be, was not enough to convey all that went on inside my mind. I was overwhelmed.
Being wheeled on a wheelchair in your hospital, where you have always been seen as the saviour of sorts is an experience in itself. I had enough of it during my hospital stay. It had cleansed my ego reasonably. The threat that somebody may recognise me may sympathise with me for my plight had diminished substantially. I had learned to see myself as an ordinary patient, that too a corona patient. I had made a truce with my corona. A disease as severe as this has a taming effect on you. Knowing that life is uncertain is far different than seeing and experiencing this uncertainty all by yourself. My corona helped me do that. It was a first-hand experience of hospital and disease for me from the patient’s viewpoint.
I sat in my car waiting to be driven back home. The sun was so bright that it dazzled me and I felt there was so much of a rush in the hospital and on the road. It was as if a new baffling experience. Everything looked so new, bewildering to me. Life had as if started all afresh for me. I was about to enter the same old world as a new man!