Fever: A misunderstood friend

Recently, a friend with a speech impairmentgestured to convey that his son had a fever. He tapped his hands over the forehead and frowned. That was enough for me to understand what he was saying. I tried finding the correct gesture in sign language for fever and realised that he had just used it. The gesture is similar to numerous emojis meant to convey fever. This always makes me wonder. Foreheads are the coolest part of the body even when someone has a fever.

Despite being the coolest part of the body, the forehead temperature check was the most popular screening method to check for fever during the COVID-19 pandemic. This is probably because it is the most accessible part of the body. A showroom or shop with an appropriately dressed man (and very rarely a woman) with a temperature gun was meant to convey that it is a safe place that is following COVID-19 protocols. Once I was rushing to check in at an airport and I asked the person with a temperature gun if my temperature was OK. He responded, “You are very cold, sir!”

The forehead is the most exposed part of the body and when someone sweats, it can become cooler than the rest of the body. When temperature guns became popular for checking fever, many people questioned its safety. It was then said that these gadgets do not emit any rays but collect rays emitted by the body and convert it to an electric signal, which is then displayed as temperature. Some people objected to having a gun-like object pointed at their forehead. In response, the norm changed to checking temperature on the wrist, which is also said to be more accurate.

Coming back to the question of fever, it is defined as having a temperature above the normal range due to an increase in the body’s temperature set point. The increase usually follows an infection. Like cough, fever is part of the body’s defence mechanism. Canadian Physician, and one of the founding professors of John Hopkins Hospital in the USA, Sir William Osler once declared, “Humanity has but three enemies; fever, famine, and war, of these by far the greatest, by far the most terrible, is fever.”

Fever was considered to be a disease in itself. It was much later that we learnt that fever is a manifestation of some disease usually an infection. It is not surprising that the symptom was mistaken for the disease as fever caused by infections has been a major cause of mortality in humans for over 200,000 years. Until the late 19th Century, approximately half of all humans were said to die from infections before the age of 15. Fever, as the most ancient hallmark of disease, dates back to a time before civilisation. By the 18th Century, fever was thought to be ‘a harmful by-product’ of infection. In the 16th Century, Italian Astronomer and Physicist Galileo Galilei invented the thermoscope, which was an equipment to measure changes in body temperature, including fever.

Fever has evolved as a defence mechanism. It is said to contribute to the host’s defence as the reproduction of pathogens can be hindered at higher temperatures. Fever has been described in various medical texts as assisting the healing process. Studies on various warm-blooded vertebrates suggest that they recover more rapidly from infections or critical illness when they develop a fever. Other studies suggest reduced mortality due to bacterial infections when fever is present.

Fever is a matter of great concern for parents and healthcare professionals, especially ones dealing with children’s health. This is because fever has been associated with dreaded outcomes in children. Doctors and parents often fear febrile convulsion (commonly called fever fit). However, we must remember that such convulsions have no correlation with the degree of fever and that not every child who has fever will develop a febrile convulsion.

Many people also develop fever after a vaccination. It is regarded as a good sign as it suggests that the body is reacting to the vaccine and developing the required antibodies to help the body’s immune system fight specific infections. Though many would argue that this fever does not need to be treated, very high fever must be controlled with antipyretics. A fever that is recurring after vaccination needs medical attention as it may be due to other causes.

Sponging is a popular method to reduce fever. While using such a method, it is important that we use lukewarm water or water at 35 degree Celsius to be precise. This is because cold water can cause closure of the vessels and hamper the transfer of heat from the core of the body where it is produced, to the skin, where it is lost. In other words, cold water will trap the heat inside the body. When the fever exceeds 38 degree Celsius, it is important to control it and avoid any further increase as it may lead to seizures. The sponge method is an effort to bring down the body’s temperature and provide comfort to the patient. Sponging is particularly important for infants and the elderly when they suffer from high fever, as they are more prone to such seizures. However, we must remember that sponging is not a treatment for fever. It only helps control body temperature.

Medications that lower fever are called antipyretics. As of 2019, studies correlating the use of antipyretics and the risk of death in those with infection have reported mixed results. In animal studies, worsened outcomes have been reported with the use of antipyretics in influenza as of 2010. However, such studies have not been carried out among humans. Already, there are different opinions among doctors on when to treat fever. Most fever guidelines advice treating fever above a certain degree only and they discourage the use of antipyretics in mild or even moderate fever. It is likely that the use of antipyretics to treat mild to moderate fever will be discouraged even more commonly in the future.

Fever can also be produced ‘artificially’ by a patient. This is done by artificially heating the thermometer or by self-administered pyrogenic substances. An artificial fever might be suspected if the pulse rate is significantly less than what would be expected for the degree of fever noted. One should consider this diagnosis for all patients when there is no other plausible explanation for a fever. Some patients who pretend to have fever may actually have a serious mental illness that may require medical attention.

On a lighter note, fever definitely needs more positive publicity. It does not help that it is often used to describe intense, nervous excitement as associated with sporting events, rock shows and political gatherings with terms such as cricket fever, music fever, and election fever. Perhaps a more appropriate word for these ‘symptoms’ is mania or collective madness. Unfortunately, no doctor can cure these ‘symptoms’!

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

A chattering of coughs

Ahem. Here I am again! I am writing after a long time on a medical subject and its ‘cough’ this time. Cough can be a symptom for a diversity of diseases. Ahem! The sound of clearing your throat or a solicited cough is also used to attract attention and express disapproval, or embarrassment.

A cough can be dangerous in certain places and social contexts. For instance, I remember an incident when I was a cadet in the National Cadet Corps (NCC). During an army attachment camp, we were given a class on various war tactics including ambush. During the discussion on selecting the ambush team, the grey-haired Havaldar Major said, “Make sure no one in your ambush team has a cough!” We did not ask him for any reason!

A cough is your body’s way of responding to something that irritates your throat or airways. An irritant stimulates nerves that send a message to your brain. The brain then tells muscles in your chest and abdomen to push air out of your lungs to dislodge the irritant.  Thus, a cough is a protective mechanism. It helps the body to expel what it does not need. One example is when you are drinking water and some of it accidently enters your throat or the windpipe. Your body coughs it out. Similarly, you cough out respiratory secretions produced during an infection. Sometimes it can be an irritant. Sometimes it can be a wrong signal. For instance, wax in your ear can also make you cough as the throat and the ear canal have a common nerve. 

An occasional cough is normal and healthy. A cough that persists for several weeks or one that brings up discoloured or bloody mucus may indicate a condition that needs medical attention.

Almost every child in Ladakh has managed to get ‘Spitchham’ (spring flu/cold) after almost two years of a COVID-19-imposed school break. At present, children are once again being exposed to various infections, which is helping their bodies build up their immunity. This did not happen over the past two years as schools were closed and children remained in the relative isolation of their family homes.  

A cough that follows a viral infection may last for periods ranging from a week to three weeks. I often wonder about the best treatment for a viral infection: Medication or time? Many doctors would argue that time is the best cure as our body needs a few days to treat a viral infection as it develops immunity against the virus. So, is it necessary for us to visit a doctor? I would argue that one should visit a doctor who can then check the kind of cough and ensure that it is not associated with any form of pathology.

Some coughs last for a short time but some persist and linger. I often meet parents who say, “Everything is ok. My child goes to school, sleeps well and eats well but has been coughing for the last two weeks.” I sometimes wish I could respond by saying, “Sorry, I can’t do anything for this cough!” On an average, such coughs will last for one short week if treated or seven long days if left untreated!

Many parents give their child a cough syrup for a cough before they decide to visit a doctor. And they are rarely satisfied until the doctor changes the cough syrup during their visit. In my experience, we need to be more careful with the use of cough syrups. I find that cough syrups are a very typically Indian response to cough! We must remember that many cough syrups have been banned and many contain an irrational combination of drugs. Then there is a cough variant asthma. The symptoms are not like classic asthma, which includes shortness of breath and wheezing. Cough variant asthma is diagnosed based on being treated with certain medication and family and individual medical history that includes different forms of allergy. I would use the kind of medication that comes in the form of inhalers for a frustrating cough when other forms of treatment fail to treat the symptoms.

However, there are challenges related to the use of inhalers that we cannot ignore. Generally, many people have a misconception that inhalers are only meant for the elderly, which means many people refuse to use them. Others fear that inhalers are habit forming with various kinds of side effects. In my experience, inhalers are helpful and the drugs they contain have minimal side effects as they are in micrograms and very target specific i.e. they are delivered only where they are supposed to work.

Let me explain this with an example. Generally, a bitter-tasting drug is supposed to dilate the airways or supress a cough. However, if we ingest them orally they will first go to the stomach. Such medications are often laced with sugar and flavours to appeal to children and people sensitive to various tastes. The medication enters the stomach, where it may cause some irritation and in some cases even cause a child to vomit. It will then be absorbed into the blood and reach every part of the body. As it passes through the brain, it can make a child sleepy or drowsy. It can cause other such side effects on its way to the lung where it is supposed to act. In contrast, when you take the same drug through an inhaler, it goes directly to the airways and dilates them.

In the COVID-19 era, cough has received a lot of attention! Recently, researchers have started experimenting with the use of artificial intelligence (AI) to analyse different kinds of data to assist with diagnosis of various diseases. For instance, experiments are being conducted where cough sounds are being analysed by AI algorithms to detect and diagnose different types of known diseases such as pneumonia, pulmonary oedema, asthma, tuberculosis (TB), COVID-19, pertussis, and other respiratory diseases. I have my reservations with this approach to screening patients and diagnosis. There is a wise saying about coughs. It advises, “Cough of more than two weeks can be tuberculosis.” And the most reliable way of diagnosing tuberculosis is through a simple sputum examination. Tuberculosis of lung alone can produce a variety of coughs depending on the location of the infection. Thus, the use of cough sounds and recording as a screening tool may not be sensitive to such differences and so remain unreliable.

In addition, one can also have what is called a psychogenic cough, which is also called habit cough. We have all experienced situations where you know you should not cough and you try to supress your cough. Then you finally cannot supress it anymore and end up coughing much to your embarrassment. Nowadays, coughing of any kind attracts a lot of attention in public places each time there is a spike in COVID-19 cases.

Finally, there is the COVID-19 and the non-COVID-19 cough! Over the last two years people have developed their own methods of differentiating between the two and its often ‘more effective’ than many diagnostics tests and AI algorithms. Simply put, when someone else is coughing, it is a COVID-19 cough unless proven otherwise! At the same time, the cough one is having is always a non-COVID-19 one, which is generally ‘caused’ by a banana, beer or cold water!

By Dr Spalchen Gonbo

Dr. Spalchen Gonbo is a Paediatrician based in Leh.

Air evacuation of patients

It is 2016. We are lucky. A tourist in the executive class vacated his seat after declaring, “I can sit anywhere.” He moved to one of our seats in the economy class. An executive class seat has more space to accommodate our medical equipment. Unfortunately, the family of the patient was able to arrange only two seats in the executive class. The father had the baby on his lap fixed to a board. I had the breathing equipment in my hand with the oxygen cylinder strapped on my back.

We thanked the gentleman and settled down on the three seats that were now available to us. The father moved the armrest back as I unhooked the oxygen cylinder and handed it to the ground staff as we are not allowed to carry an oxygen cylinder on commercial flights. The airhostess handed me the onboard oxygen cylinder that we had booked in advance. However, there was a problem. The piping on our machine did not fit the new oxygen cylinder. The other oxygen cylinder had already been removed from the aircraft. I asked the airhostess for a blade. She looked at me suspiciously and said, “Blade on an aircraft?!” She then approached the pilot who emerged from the cockpit to give us the required permission. The airhostess took out a small box that contained articles such as bandages, a scissor, and a blade. I noticed that the pilot kept an eye on me as I took the blade and waited till I handed the blade back to the airhostess after cutting the pipe and fixing it to the new oxygen cylinder. We made it to New Delhi with no incident.

Fast forward to 2021. The neatly dressed officer in an air force dungaree declared, “We don’t have an oxygen cylinder on board! We do not have a stretcher either. You can carry whatever you want!” The nurse and ambulance driver who had dropped us to Leh air force base wanted to take the stretcher and cylinder back as it was in their ‘charge’ but I was not in a position to part with either. Finally they pleaded, “Doctor-saab, please bring the stretcher and cylinder back to Leh.” It was a smooth flight in the C-17 aircraft from Leh to Chandigarh. Later, the father used a private transporter to send the cylinder and stretcher back to Leh.

These are just two stories of air evacuation of sick patients from Ladakh for treatment that is not available here. Such cases require a lot of effort by the patient’s family along with intervention by the administration and help from the airline/air force. It is difficult to arrange such an evacuation at a short notice. There have been hundreds of such evacuations from Ladakh in addition to commercial air ambulances that cost in excess of INR 7 lakhs (INR 700,000).

We must constantly work to improve our healthcare system. COVID-19 has shown that a fine line separates life and death. This reality was driven home for me when I watched four of our doctors admitted to the COVID-19 ward during the second wave in 2021. Similarly, a fine line separates a patient and a healer too. A senior physician once told me, “It is for us, nono!” after I congratulated him when we acquired an ECHO machine and added that it would benefit patients. This is when he explained that it was not just for patients and that healers can become patients anytime. I saw a lot of wisdom in his words.

There are two district hospitals in Ladakh: Sonam Norboo Memorial Hospital (SNM), Leh and District Hospital (DH), Kargil. Both of them have recently undergone a major change in their status. They were two of 24 district hospitals in the erstwhile J&K state and are now the main hospitals of UT Ladakh. Since we do not have many facilities in these hospitals, referral is an important approach to treat many cases. This is also important when we provide care to high profile delegates who visit Ladakh.

There are plans to have a doctor and medical facilities in every corner of Ladakh irrespective of the population size. This is in contrast with Sri Lanka, which has a centralised system. Though Sri Lanka is a developing country, it has a good healthcare system. They have very few tertiary care centres and referral units function as stabilisation units. These units do not have doctors and are staffed by trained paramedics. These units are connected by an efficient transportation system, which includes helicopters and air ambulances to transport patients to well-equipped tertiary care centres.

Another approach is to use commercial aircrafts for patient evacuation. I am told that every flight from places such as Port Blair has nine seats reserved for patients at a nominal cost. Such a system would benefit people who cannot afford an air ambulance. Nine seats provide enough space to carry a patient on a stretcher along with a doctor, a nurse, and a relative and is much cheaper than an air ambulance.

We need to streamline the referral and evacuation system, as we cannot have every facility at our hospitals. It is simply not cost effective as many of them are not required on a regular basis. There have been instances in India in the recent past where patients have been referred to foreign hospitals by the government to receive treatment that is not available in the country. The Nirbhaya case was one such example. Thus, services provided by any hospital can never be ‘complete’.

At present the government has a state-sponsored referral system to the nearest tertiary care centres in Kashmir. However, we need to expand this to create an efficient air evacuation system, especially when we have no surface connectivity in the winter. The government currently pays for the air ticket of a patient and an attendant under the Janani Shishu Suraksha Yojana (JSSY). However, we need to streamline the process. At present, the army and the air force provide support to transport critical patients. However, their aircrafts are often not equipped to transport critical patients. At the same time, it requires a lot of paperwork to use commercial airlines including provision of basic facilities such as an onboard oxygen cylinder. It thus makes sense to have a more streamlined referral system for air evacuations from Ladakh with possible subsidies and support from the government.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

Anaemia in Ladakh

We often hear the word ‘highest’ being used in relation to Ladakh. The world’s highest motorable road, the highest dosa point in the world, and the highest ATM in the world are a few examples. Recently, Ladakh featured in the national news for having the ‘highest’ prevalence of anaemia in children in India at a whopping 92.5%. Well, many might have recorded it as a fact, but this got me thinking. Who collected the data? Who compiled it? And, who interpreted the data? Was it interpreted correctly? Was this another case of armchair research?

According to the National Family Health Survey (NFHS) data, over 50% of the Indian population is anaemic. As in other parts of India, anaemia is a public health issue in Ladakh too. However, when is said to be prevalent in 92 % of children, the data needs to be scrutinised more closely. The reasons cited in the news article I read for this prevalence were plausible. It argued that Ladakhi children do not have access to green leafy vegetables and fruits for a major part of the year. It also mentioned that crops are grown in the summer and that in the winter people do not have a regular supply of fresh produce.

On the contrary, I think that most Ladakhi children at present enjoy a good meal even if they do not always have access to different varieties of fruits and vegetables as enjoyed by other Indian children. Anaemia was also cited as a reason for Ladakhi children being stunted. Well, this has to be interpreted in the context of genetics, which play an important role in the height of a person. Most high landers are shorter than the average human. This is said to be a part of their adaptation to life in a high altitude area. In fact, I rarely see a severely malnourished child in my practice. Maybe we are not doing justice to this issue as we are using the standard chart developed by Indian Academy of Paediatrics, which adapted the WHO chart for the Indian population. I don’t think any studies were done on Ladakhi children to prepare this chart.

Anaemia at high altitude has always been overestimated. Haemoglobin level at high altitude rises in response to hypoxia. The body increases the carrier of oxygen i.e., haemoglobin to compensate for the lack of oxygen in the atmosphere. When we have more haemoglobin, we will have more oxygen molecules supply to each tissue. So, when we calculate haemoglobin at high altitude a correction has to be made to compensate for the increase in haemoglobin in response to lack of oxygen. Simply put, if your haemoglobin level is nine it will be recorded as seven. Similarly, in cases your haemoglobin level is 13, which is not anaemic, it is recorded as 11, which is regarded as anaemic. This is because the extra haemoglobin value is due to high altitude, and has to be subtracted to calculate the actual haemoglobin value. As a result, many children are being recorded as anaemic. The correction is based on research carried out by the American health agency Centers for Disease Control and Prevention (CDC) based on studies done among high altitude communities living in the Andes. This may or may not apply to the people of Ladakh.

The correlation is complex. The adaption at high altitude communities in the Andes is said to be different from that of the communities living on the Tibetan plateau. It is said that the Andean communities have not developed the physiological adaptations to high altitude conditions as evident among the residents of the Tibetan plateau. Furthermore, it is not clear to me if the anaemia study only focussed on haemoglobin value or if a more detailed investigation was carried out. We need to know if a person is truly anaemic before we label them as anaemic. This requires more tests in addition to their haemoglobin level. I doubt that such tests were done. In fact, I am not aware of any large study on anaemia in the last 20 years in which important parameters such as iron levels were done without which we cannot reach any conclusion about anaemia prevalence.
I am aware of one study involving 840 students in Leh district that was done by a Netherland-based NGO called School Health Checks. After recording data over two years, the interpretation of the data was interesting not only because of its results but also because of the actual observation. This study assessed haemoglobin through spectrography (Hemocue) using blood drawn from a finger prick. When someone had very severe anaemia say a haemoglobin level less than 5.5 gm per decilitre), they carried out more advanced tests such as a smear examination at Sonam Norboo Memorial Hospital in Leh. Other advanced tests such as iron studies, B12 and folate levels were not done.

After recording the data, they interpreted it using the CDC correction based on chronic exposure to high altitude. They concluded that the prevalence of anaemia among school students in Leh as 82%. They were astonished by the result as they had physically examined all the children. The pattern of distribution of anaemia among different age groups did not correlate with other known population groups. The investigation team included a qualified physician, a paediatrician, a biologist, and an epidemiologist. Based on the conclusion that emerged, they were sure that something was wrong with the result, the methodology or that the criteria they were using was too strict. So they applied a mild correction recording the altitude of Leh as 2,000m above mean sea level (amsl) and that of Turtuk as 1,500m amsl. They then applied the CDC criteria once again and the anaemia prevalence was 66%, which is still higher than the national average. Another interesting observation they made was that Ladakhi children eat a large amount of sweets, chips and packaged noodles, which may have contributed to the anaemia. They also observed that often parents are the ones who provide children with these products for consumption. It is interesting to note that during the COVID-19 pandemic when children were at home, the intake of such food has increased manifold and probably so has the prevalence of anaemia.

In this regard, a more detailed study with a larger sample size is required. It is said that we are drowning in data but starved of knowledge. This is especially true in this case of anaemia in Ladakh. If data is misinterpreted, it will make no sense or can be senseless or even disastrous. The base of the data analysis pyramid has a pool of data. The layers above include information and knowledge. The tip of the pyramid is wisdom. This implies that right analysis and use of data can lead to wisdom. Our understanding of anaemia in Ladakh has a long way to climb, on this pyramid.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh

Do not let it go!

As the father entered my clinic with his ailing child, I could not help wonder why they were travelling at a time when the world was still struggling to manage the COVID-19 pandemic. The child had an acute respiratory infection along with acute mountain sickness. I voiced my thoughts and asked him, “Why are you travelling?” I wanted to understand the thought process of someone travelling for leisure when the whole world was still reeling from the COVID-19 pandemic. It seemed rather odd to me. We are still in the midst of a pandemic that has spread along travel routes. There is no doubt that the man standing in front of me was a good father and I could see how deeply he cared for his child, “I had promised him a trip a year back but we were not able to travel due to the COVID-19 outbreak. Just as the lockdown eased this year, we decided to pursue the plans we made last year. Now, I see that it was a mistake.” It reminded me of a wise Ladakhi proverb, “Lda marings jaga rings” (You tolerated it [in this case, restrictions] for a month but not a day more).

Sometimes, I struggle to make sense of some people’s behaviour especially when it puts themselves and others at risk. Perhaps, they are in some sort of denial. Or, perhaps they are trying to forget the events of the recent past. People seem to be looking for any reason to step out of their homes to explore the world and meet people. This is not reasonable behaviour to cope with a pandemic. The behaviour of the youngsters especially seems dangerous. It is evident on social media platforms where one can see youth inciting and challenging others to follow suit. People seem to be tired of restrictions imposed to curb the spread of COVID-19.

Sometimes I am amused to see so many people roaming around unnecessarily and helping the novel coronavirus spread. And yet, it is painful to see a tourist, who has been travelling to different corners of Ladakh for more than a week, test positive for COVID-19 when they are tested in preparation for their return journey. We are in the midst of the second wave and anticipating the third wave soon. We cannot take chances with this virus. Perhaps touring is something that we can delay for a little while longer. Going out unnecessarily not only exposes us to infections but also increases risks for others who we might meet during our travel.

We have all faced difficult times since early 2020. People have spent most of this time indoors. They have been maintaining physical and social distance from others. This time has been a nightmare for many people. Initially it was due to financial issues and the psychological impact of uncertainty. In due course, most people have had to face the reality of the pandemic in the form of personal losses due to lives claimed by COVID-19. Many children have been orphaned after their parents died of this dreaded disease. It is not surprising that people are now looking for ways to forget the past.

These difficult times will not last forever. Things will be normal again. We will be touring again. We will be partying again. We will dine with our friends and relatives soon. However, at present we need to be realistic about the challenges we face. We need to change our mind-set. We need to focus on the qualitative aspects of our lives rather than the quantitative ones.

In this context, we must not let our guard down yet. We need to embrace this nightmare for a while longer. Do not let it go! We need to let the images of overwhelmed hospitals linger in our minds for some time. We need to remember that oxygen was our basic need like food and water not very long back. We should let the sights of overworked crematoria and bodies floating in various rivers haunt us for some more time. We must not forget the bad times that we have all lived through. Only this will make us more cautious and refrain from behaving irresponsibly and inviting more pain.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

Preparing for the third COVID-19 wave

Even as the second wave of the pandemic reaches its peak in India, people are already anticipating a third wave. Pandemics and epidemics generally progress in waves before they ebb. There is also speculation, particularly in the media, that the third wave will put children at greater risk. The first wave mostly involved the elderly and those with co-morbidities. In the second wave, many people in their 30s and 40s suffered severe symptoms and fatalities. The logical conclusion drawn from this is that the next wave will put children at greater risk. This seems plausible as children and teenagers are yet to be vaccinated for COVID-19.

However, this does not account for the fact that many children, including new-borns, are already being infected by SARS-CoV-2 at present. In fact, whenever we test a child who has been in contact with an adult patient, they not only come positive but also have a higher viral load than adults. However, they exhibit milder symptoms or are asymptomatic though some children have developed moderate to severe symptoms including ones who developed Multisystem Inflammatory Syndrome in Children or MIS-C. However, these remain rare manifestations of the disease in children. That said, more infections are now being reported for children compared to earlier. In fact, the number of children infected rose to 15% in the second wave compared to 4% earlier. A recent study by AIIMS, New Delhi and WHO found high sero-positivity amongst children, which means they have been equally susceptible to COVID-19 as adults.

Children seem to have innate or acquired immunity. Innate immunity is immunity a child has at birth through antibodies transferred during the third trimester as well as antibodies found in the mother’s milk that offers protection from various infections in the first year of life. It may also be an acquired immunity, which is something a child develops in response to infections. For instance, children in day-care centres and schools are exposed to many respiratory infections, which may result in them having a higher baseline of antibodies for respiratory viruses. This might provide some protection from SARS-CoV-2.

We see respiratory infections as a disease of children. In fact, many children suffer at least one episode of cough and cold each year and, unlike adults, they develop high fever and severe symptoms. Crèches and schools are ideal breeding grounds for such viral infections, and many children get infected at the same time. Through such incidents, children develop immunity that lasts for a long time. This immune response possibly provides cross immunity for SARS-CoV-2. However, it is worrisome that schools are currently closed and there is less community transfer among children. Thus, the immunity may wane over time and children may start developing symptomatic infections including COVID-19.

Also, adults suffer a more severe impact from COVID-19 due to an overreaction to the virus (cytokine storm) by their robust immune system. The young and naïve immune system of a child will give a normal response rather than an aggressive immune response when they get the virus. The intense immune reaction is what causes damage—often irreversible—to the lungs and other organs in adults.

Vaccination is the only plausible explanation for the shift in the age group of people severely infected by COVID-19 in India’s second wave. Vaccination and precautions are protecting the elderly. This might imply that a proportionally higher number of children will be infected in the third wave if they are not vaccinated even if they suffer fewer symptoms. It is also possible that early communication on COVID-19 focussed primarily on risks faced by the elderly. Younger people may have been a little careless and faced greater exposure to the virus. We were unprepared for the second wave. We are now anticipating the third wave. There is an urgent need to increase the vaccination process in India and include the paediatric population, especially those over 12 years of age. At the same time, we must create and upgrade infrastructure to treat children across the country. We must learn from our own failures and the experience of countries where a number of children died from COVID-19.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

The power of causality

As of 1 May, 2021, all adults in India are now eligible to receive the COVID-19 vaccine. Very soon, the vaccine will also be made available to the age group that is most vulnerable to COVID-19: Children. However, that will only happen once the safety profile of the vaccine becomes clearer. This is how vaccines evolve. In the chronology of vaccine development, we are past the Phase III trials for COVID-19 vaccines and are now in Phase IV. Generally, companies receive licences for vaccines once they successfully finish Phase III trials. After this, the effort is to generate more data to improve the safety, efficacy and effectiveness of the vaccine with the ultimate aim to save more lives with minimal side effects.

As with all vaccines, the COVID-19 vaccine too has evolved. Thankfully, it is becoming clearer that the vaccine is effective in preventing infection and serious symptoms and deaths. Unfortunately, many of us have been labelling many ailments they suffer as side effects of the vaccine. Most side effects actually caused by the vaccine were temporary and expected. Of course, with time the vaccine will become safer just as the current vaccine is safer than its initial versions. Vaccines are constantly improving based on unwanted effects observed in people. This is the beauty of medicine, which is not only a science but also an art. Knowledge, skills, and tools evolve over time and are constantly improving.

How does one navigate the deluge of information and misinformation online on the side effects of the COVID-19 vaccine? In my opinion, it is important to be cautious and critical but not trust hearsay. One way to do this is to focus on causality. Say there is an observed effect (say some ailment), which is attributed to a cause (in this case the vaccine). It is possible that the observed effect is not due to the assumed cause. In statistics there is the concept of P value that provides insights on how significantly a cause is correlated with an effect.

In this context, if a dangerous side effect is more evident in a population that has received a drug or vaccine than the general population, then the effect has a higher correlation with the cause as evident in its P value. Thus, if the P value is significant we can infer a cause-effect relationship. Using this rationale, the side effect of blood clotting that many attributed to the vaccine was found to be statistically insignificant. In addition to such an evaluation, one must also weigh risk and benefit of a medicine and vaccine. So for instance, one might have to weigh the possibility that a vaccine may cause some side effects that are not life threatening on the one hand with possibility of the risk of contracting a dreaded disease in the absence of a vaccination.

People have a tendency to relate some effects to some causes irrespective of their actual correlation. This depends on a variety of factors including personal experience, social beliefs and trends. As a doctor, I have been witness to this many times. Many parents have told me that their child was vomiting in the morning but also started experiencing diarrhoea or had developed a rash after taking the medicine I had prescribed. Many times such correlations are illogical. For instance, people relate a variety of food with sore throat, fever, abdomen pain etc. but rarely correlate smoking or alcohol with any of their known side effects! Research has shown a very significant correlation between smoking and various forms of cancer. Similarly, consumption of alcohol correlates with various forms of cancer and hypertension to name a few effects. Thus, the tendency to draw certain cause-effect relations often reflects personal and social biases rather than actual correlations.

This conclusion was driven home for me recently when a friend developed a sudden deterioration in his vision. He is 22 years of age and required prolonged treatment to recover completely. I am glad that he is fine now. However, I was also relieved that he developed these symptoms before taking the COVID-19 vaccine. He was planning to get the COVID-19 vaccine as he works in the healthcare sector when he developed these symptoms and he had to defer the vaccination. I am certain that if he had developed these symptoms after taking the vaccine, many people would claim that it was a side effect of vaccination as he is too young to have such a disease. 
It also reminded me of an incident from my childhood. We used to visit an archaeological ruin at Gyamtsa, which local folklore said would have been similar to Alchi monastery had it been completed. According to the folklore, some divine beings were building the monastery and they wanted to complete it before dawn when humans would wake up. However, a donkey started braying in the middle of the night. Donkeys generally bray for different reasons, including the onset of dawn. However, in this case this donkey started braying in the middle of the night. On hearing the donkey, these divine beings ran away and the monastery remained incomplete. I still blame the donkey whenever I pass the ruins! I now realise that am being unfair to the donkey. A donkey brays at dawn but its braying does not cause dawn. Thus, I should be blaming whoever started correlating dawn with a donkeys braying.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

The selfie vaccine

When my friends in America and UK started posting selfies as they were given the COVID-19 vaccine, I started asking myself, “Mera number kab ayega?” (When will my turn come?). The reason for my impatience was not about the selfie but the result of my hope and confidence in my country and its scientists. When the day finally arrived, I rolled up my sleeves and submitted myself to the person administering the vaccine. In my excitement I did not even feel the needle prick. But I did hear the vaccinator mutter, “Ya Konjok Sumbo Khen!”(O Gods, you know everything!)

Photos of healthcare workers (HCW) receiving the vaccine started flooding social media. HCWs were encouraged to be active on social media to spread a positive message about the COVID-19 vaccine. Such public action helps allay hesitation that may exist about such vaccines in a community. It helps people realise that the vaccine is safe and that it should not be feared. It is said that many people may not trust the government or any institution but they do trust the HCWs with whom they have direct contact. The photos of HCWs receiving the jab became so commonplace that people started making jokes about it. For instance, there were light-hearted suggestions that the government should give the second dose on the buttocks to prevent people from taking a selfie! A friend posted a photograph of him receiving the vaccine and wrote that a DNA chip was inserted in his body and added wryly that he was “still a human and had not turned into a mutant”. He possibly wanted to allay fears that the vaccination is a means by which the government will started controlling people through a microchip. I have heard some people claim that such vaccines induce sterility. I often wonder that if such a miracle was possible, then the government would use it immediately to control the feral dog population. Furthermore, if such a medical miracle was possible then the world’s population would not have tripled in the last 30 years. Needless to say, no such medication exists.

Vaccine hesitancy is a complex process. Some think or claim vaccines are a part of a larger conspiracy, while others claim it is part of private commercial interests, especially pharmaceutical companies. Yet others think there are alternatives. Thus, there are numerous misconceptions about vaccines. It is said that vaccines are victims of their own success. Several killer diseases no longer pose the same fatal threat to humans as they did in the past and have been rendered harmless by vaccines. However, each time we fall short in our vaccination efforts, the diseases create havoc once more. A good example of this is measles, which has claimed many lives even in developed countries every time vaccine coverage has suffered.

People don’t want to be the first person receiving a vaccine but also don’t want to be excluded. When the vaccine was first announced, there were messages on social media that politicians should be vaccinated first. If nothing happens to them the vaccine is safe and if something happens to them then people are safe! Such messages were written to question the vaccine’s safety. However, everyone agreed that HCWs should be vaccinated on a priority basis. This was a natural choice. But HCWs are human too and also experience fear of new things. So when India decided that HCWs will be vaccinated first, there was a diversity of reactions. We saw bureaucrats assuring doctors that the vaccine is safe rather than the other way around. However, when Greece started vaccinating politicians and bureaucrats before HCWs there was a backlash. Thus, vaccinating HCWs first seems like a logical approach.

It is not surprising that on 16 January, 2021 when India started vaccinating HCWs in the early hours, many people who were scheduled to be vaccinated simply did not turn up or found an excuse to be ‘late’. However, once they saw that people who were vaccinated did not have any unpleasant reactions many people started turning up towards the later half of the day.

As a healthcare worker, I agree with India’s decision to first vaccinate its HCWs. For me it’s a privilege, a shot in the arm that is a form of recognition and appreciation to HCWs who stoically faced the brunt of the COVID-19 pandemic and helped care for infected individuals. Secondly, since this a new vaccine that is going to be administered on a large scale, it is important that HCWs are aware of potential side-effects that they can report and receive treatment immediately. This is my personal opinion.

Every country’s government is under pressure to vaccinate its citizens as soon as possible. Similarly, we have witnessed various forms of vaccine nationalism during the COVID-19 pandemic. It is not surprising that many feel that this vaccine has been produced under pressure and thus may not be safe or effective. Even if this were true, I cannot help but wonder why a government would administer an unsafe vaccine to its citizens? If any untoward incident were to occur, the government would face a backlash from its citizens.

There were other people who claimed that the vaccine is safe as it is just distilled water. I am an HCW and I have received the vaccine. I know for a fact that distilled water injections are rather painful. I can vouch for the fact that this vaccine wasn’t as painful as distilled water! Furthermore, I developed muscle pain, mild body aches and a mild sore throat after receiving the vaccine. These symptoms disappeared after a day. All these symptoms are associated with COVID-19. It makes logical sense as vaccinations are meant to produce a mild reaction of the disease to trigger the immune system to produce antibodies. Thus, I am sure that the vaccine is not only safe but also effective.

I understand people’s scepticism and fears. This vaccine has been developed in the shortest time in the history of medical science. It was developed and completed trials in less than a year. Other vaccines have been known to take around five to 10 years of development and trials. What we seem to forget is that this vaccine development did not start with the appearance of SARS-CoV-2. In fact, a lot of research and development had already been done for SARS CoV-1 and MERS. This development was halted as the circulation of these viruses had stopped. This provided the necessary foundation for the development of the SARS-CoV-2 vaccine. Thus, everything was ready and pre-clinical trials had already been done. The only piece of the puzzle that was missing to start the process was the virus.

I will say that I trust the vaccine as I know how such vaccines are developed. Though the Phase 3 trial data has not released in its entirety to the public, the data that was available was enough to convince me that it was not only safe but also effective. Furthermore, it is currently being administered as “emergency use authorisation” due to the ongoing pandemic. This means more data will emerge now. I will trust the transparency and authenticity of such data as long as the studies are not mere eulogies. Many side effects were also mentioned in the data available in the public domain though it later emerged that these were not directly related to the vaccine. Medicine keeps on evolving and as it is evidence-based. American scientist and writer, Issac Asimov once wrote, “The saddest aspect of life right now is that science gathers knowledge faster than society gathers wisdom”.

We have to trust science and in the process of vaccination development while also retaining a healthy and reasonable level of scepticism. However, mistrust to the point of cynicism is invariably harmful.

“Ya Konjok Sumbo Khen!”, the vaccinators prayers is still ringing in my ears. She probably repeated the prayer throughout the day with the hope that the vaccine does not cause harm to anyone and serves its intended purpose. In a way, it reflects the general scepticism we all have. However, we all know that we are in the middle of a pandemic and can only fall back on science.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

Why humankind is suffering

Have you ever wondered why stray animals that eat from the garbage bin rarely fall sick? Or how our pets who consume the family’s leftover food manage to remain hale and hearty? In contrast, we have been washing our hands, using different kinds of sanitisers, wearing a mask and eating fresh and clean food. Despite this, we seem to remain at constant risk of all kinds of pathogens. Why are humans so weak? Or, what has made humans so weak? The reality is the exact opposite. Humans are fairly strong but we suffer due to our behaviour and actions.

In the wake of the COVID-19 pandemic, it’s definitely a good idea to maintain a very high degree of hygiene. I have now learnt to trust the wisdom of the famous Ladakhi word: Lobs, which means “getting used to”. For instance, elders often say, “Don’t give boiled water to your children all the time or they will get used to it.” Most of us have survived on tap water and stream water while our children have grown up on filtered and boiled water. Similarly, the elders also say, “Oh, don’t wear that feather jacket. What will you wear in the winter?” In the same vein, they would also say, “Oh, don’t keep that baby so clean all the time, let it play in the dirt. It will make the baby strong.” Yes, diarrhoea and similar infections are most common among children who maintain a high level of hygiene. I have noticed that children from Europe and other developed countries are very susceptible to diarrhoea and contact infections such as Hepatitis A when they visit India.

Our immune system is very strong and dynamic. Though it faces challenges tackling some pathogens, our body is able to deal with most pathogens and provide immunity cover for the rest of our lives. Over several generations, we have developed an innate and natural immunity for many pathogens. In this regard, the novel coronavirus is different as it is a new virus that may have come from wild animals or may even be “artificial”…who knows!

This year has been exceptional in many ways. Besides the COVID-19 pandemic, other diseases seem to be lying low. For instance, we didn’t have diarrhoea during the diarrhoea season. Similarly, we always get several patients with pneumonia or the common cold in the hospital but the numbers have been much lower this year. In fact the incidence of most infections seems to be at the lowest I have ever seen. I cannot help but wonder what happened to the never-ending line of children in our OPD and the clinics. And what happened to waterborne diseases such as diarrhoea and jaundice?

We contract most infections due to our behaviour and actions. Our body has evolved to fight off most infections. However, most epidemics are caused by pathogens that originated in nonhuman animals. These pathogens do not cause their host animals any harm and become virulent when they manage to jump to humans who do not have any natural immunity to such new viruses. Similarly, we too have pathogens in our body that do not harm us but can cause infections in other species that lack immunity to them. Such ‘good bugs’ help us remain healthy. Through the course of history as we started domesticating and consuming various animals, many of their ‘good bugs’ started mutating and crossing over to humans.

A good example of this process is measles, which is caused by the measles virus. Measles is a common infection amongst children. It has caused epidemics and claimed the lives of millions worldwide. This virus is said to be closely related to the Rinderpest virus, which is a pathogen found in cattle. It is believed that the smallpox virus shares many similar characteristics. Smallpox has wiped out whole civilisations. Most researchers assume that animal domestication and their consumption that started around 6,000 to 10,000 years ago, created conditions that facilitated the emergence of smallpox. Similarly, a virus that causes common cold-like symptoms in humans originated in poultry and may have crossed the species barrier around 200 years back according to an article in the Journal of General Virology. An international team of scientists traced the origins of human tuberculosis to early humans when they lived in hunter-gatherer groups in Africa some 70,000 years ago. Similarly, chimpanzees in West Africa have been identified as the source of the HIV infection in humans. It is believed that the chimpanzee version of the immunodeficiency virus (called Simian Immunodeficiency Virus or SIV) was transmitted to humans and mutated into HIV after humans hunted these chimpanzees for meat and came into contact with their infected blood. Over decades, the virus spread across Africa and the world beyond. Other diseases such as Plague, Brucellosis, Lyme diseases, and Rabies have a similar history.

This seems to be true for the novel coronavirus too. We know that it originated in a wet market in Wuhan where a wide variety of wild animals like snakes, mongoose, bats, and wild cats were slaughtered for consumption. It is believed that the novel coronavirus has a zoonotic origin as it has a close resemblance to the bat coronavirus. However, there are some claims that pangolin may have served as an intermediate reservoir for the virus as it passed from bats to humans.

Overall, it seems we are suffering largely because of the suffering we have inflicted on animals and other life-forms. Although humans are physically small, our brain is disproportionately large and has enabled us to control the whole planet. In fact, many species have become extinct due to human activities.

Humans have long consumed other animals as food. This may have been relatively safe when these animals were raised in the backyard. However, this is now being done on an industrial scale and has become inhuman and unethical. In the last 50 years, while the human population has doubled the amount of meat being consumed has tripled in addition to the tonnes of fish being harvested. Intensive farming operations housing tens of thousands of animals in close quarters serve as ideal incubators for disease transfer of infectious agents from animals to humans, antibiotic resistance, food-borne illness, and the emergence of new viruses like the novel coronavirus. Antibiotic resistance, stems from the use of antibiotics to promote growth and suppress disease in confinement operations and poses a serious health concern. In fact a majority of the antibiotics produced are consumed by animals that are then consumed by humans.

Furthermore, the ever increasing demand for food has shifted the focus from ethics to efficiency. Animals are now being slaughtered by machines and through electrocution, which are painful. At the same time, many industrial farms employ procedures such as de-beaking, de-horning, de-tailing, castration, overcrowding etc. to increase their meat output. However, these practices cause physical stress to the animals and there is growing concern that meat produced in such facilities is laden with various stress hormones in addition to various pathogens and antibiotics.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

Vaccines do not save lives…

It is said that only fear brings people together. And, when the fear is that of death, the world will surely come together. In the wake of the COVID-19 pandemic, we have seen the world unite to develop a vaccine against the disease. Everyone seems to be waiting eagerly for a vaccine that will prevent COVID-19. Even people who otherwise oppose vaccines and those who regard vaccinations as a marketing conspiracy are now pinning their hopes on various trials underway.

However, this unity has turned into a contest, which is reminiscent of the race to reach space. And this time too, Russia seems to have won with its Sputnik-V vaccine for COVID-19. The word ‘sputnik’ means ‘fellow traveller’ in Russian. The word holds a special place in Russia’s history after Sputnik became the first artificial satellite that was successfully launched into space. At the time, Sputnik was way ahead of its time just as Sputnik-V is now. It has left the world, especially Russia’s Cold War rival, the U.S. of A, in a state of shock.

While the competition to master space flight was indeed a race, the development of a vaccine should not be treated as a race or contest. Many compromises are being made in this race to develop the first vaccine for COVID-19. According to various reports, Sputnik-V has not even completed its Phase 3 trials when it was declared a success. Many countries are bound to reject it till it undergoes more rigorous tests. The UK has already said it will not use Russia’s vaccine at the moment. Safety and effectiveness are key components of a vaccine. Most vaccines that are currently being used have taken anywhere from five to 10 years of development and have undergone five phases of testing.

We seem to have forgotten an important principle of medicine. Vaccines are but one strategy to prevent to prevent a disease. We must treat the COVID-19 vaccine as one of many approaches to control the disease and make it our only strategy. There are many different measures and non-pharmacological interventions to control the spread of the virus that can be implemented immediately but remain neglected. Furthermore, in the race to find a vaccine for COVID-19, we have started ignoring all other diseases and routine vaccinations that are putting people at unnecessary risk.

Let me put this in perspective. The seriousness of a disease is calculated in terms of mortality or death that it causes. I pulled up statistical data from the websites of World Health Organization and Medscape for diseases that have a relatively high mortality rate for which vaccines are available but are not mandatory. This includes Varicella (4.2 million complications and 4,200 deaths worldwide each year), Influenza (three to four million and up to 500,000 deaths worldwide each year), Hepatitis A (7,134 deaths in 2016), Pneumonia (2.56 million deaths in 2017), Hepatitis B, which is regarded as 100 times more infective than HIV and causes around 884,000 deaths each year. A total of 570,000 women were diagnosed with cervical cancer worldwide in 2018 and it claimed the lives of 311,000 women that year. Then there are serious bacterial diseases such as meningococcal meningitis whose mortality rate can exceed 50% if left untreated. Vaccines are available for all these diseases but most people do not receive them as they are ‘optional’ in many countries including India. Most people don’t regard these vaccines as necessary as the deaths caused by them are not as ‘visible’ as COVID-19. Many vaccines currently being administered such as BCG and MMR are said to provide a degree of protection against COVID-19. Similarly, the flu vaccine Pneumococcal also seems to help prevent some complications of COVID-19.

The deaths attributed to COVID-19 are visible as we are in the midst of a pandemic. It may soon become endemic or may vanish altogether. Even now, the deaths caused by COVID-19 are less than the number of people who die in accidents, which in 2018 was estimated to be around 151,417 in India alone. There is a common misconception that COVID-19 is lethal in the absence of a vaccine. This is simply not true. So far, the highest mortality rate for the disease has remained below 3%.

Take for instance the case of the Hepatitis B vaccine, which is known to prevent certain cancers of the liver. It has now been included in the Universal Immunisation Programme and every new-born in the country is receiving this vaccine. However, most adults and elders in Leh district have not been immunised with this vaccine. I specifically mention Leh district rather than Ladakh as a whole. The reason is that Kargil recently managed to vaccinate every person in the district. The end result is that most adults in Leh district have not received the Hepatitis B vaccine despite its high prevalence in some parts of Changthang.

I am not suggesting that we should stop looking for a vaccine, stop taking COVID-19 seriously or become complacent. However, safety and effectiveness are two most important qualities of a vaccine. A vaccine cannot be produced overnight. Interestingly, I recently discovered that vaccines have also been a part of disease prevention in Sowa Rigpa. In allopathic systems, vaccines undergo five steps of development. I would argue that we should not rush the process of developing a vaccine and invest in multi-pronged approaches for disease prevention. And most importantly, we must not neglect other diseases that are still infecting people and claiming lives for which we do have vaccines and treatment protocols. Vaccines are said to be humankind’s most important invention after the wheel. However, we seem to have forgotten a very simple principle: Vaccines do not save lives, vaccinations do.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.