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.

Studying recent studies

While surfing the internet recently, I stumbled on a ‘study’ that concluded, “According to a recent study, all recent studies are false!” I could not stop laughing when I read this statement. Yet, it seems to describe the state of research in the context of the novel coronavirus. Nine months after its appearance in China and 17.8 million cases worldwide and 686,703 deaths so far (4 August, 2020), we still know very little about it. It is still a ‘novel’ coronavirus.

In fact, study results are being released every other day and a new treatment regime is being added to an already complicated treatment protocol. A vast array of drugs is currently being used to treat this virus with varying result. So far, we are using an antibiotic (azithromycin), which is meant for a bacteria (corona is a virus), an anti-viral (Remdesevir, Favipiravir), antiretroviral drugs (Lopinavir, Ritonavir) that are meant to treat the HIV virus, antihelminthic drugs (Albendazole, Ivermectin) that are meant to treat parasites, steroids (dexamethasone), anti-malarial drugs (chloroquine, hydroxychloroquine) that are meant to treat malaria, immune system boosting interferons etc. The latest addition to this list that was announced as I was writing this article is a dye called methelene blue that is used in nebulisation. All of these drugs are based on some studies. Like the now famous hydroxychloroquine, each of these drugs have been introduced as a “game changer”.

It has been a relief to have reliable and fast internet connectivity in Ladakh over the past year. The internet used to be notoriously unreliable in the past. “Is the internet working?” used to be a convenient way to start a conversation in Ladakh till fairly recently. The internet was especially helpful during the lockdown. Imagine how the lockdown would have been without the internet or an unreliable connection? It would have been rather difficult. This time around, people found solace through their smartphone and computer. Each of us has consumed a high dose of webinars and online classes over the last few months. There are several jokes online of people collapsing in front of their computer or phone from an overdose of webinars. Similarly, there have been jokes of doctors spending more time online conducting webinars as specialists on COVID-19 than actually than actually treating COVID-19 patients time in the real world. I too had to join many such webinars. While my presence was visible, I would often mute the microphone and turn the camera off. This seems to be the new way of ‘bunking’ in the online era!

A few days back, a study was carried out at the hospital where I work to check the seroprevalence of COVID-19 antibodies among staff members. We braced ourselves with the expectation that many staff members would test positive given the number of COVID-19 cases being detected and treated at the hospital. A recent study elsewhere revealed a higher load of COVID-19 infection among health workers at a non-COVID-19 facility as compared to a dedicated COVID-19 hospital largely due to the use of better PPEs at the latter. Testing positive for the antibody means that the body has developed some protection from being re-infected by the same virus. Most health workers at our hospital tested negative for COVID-19 antibodies. This meant that very few staff members had been infected by the novel coronavirus over the past month or so. It also meant that precautionary measures being taken by our staff has been effective. If these inferences are false, then there is another scarier explanation: Immunity after COVID-19 infection is uncertain if the body has not developed antibodies. This means we may get re-infected several times over while the novel coronavirus remains in circulation. A recent study says so! If true, this particular finding can be a big hindrance for vaccine development as the science of vaccination is based on intentionally triggering antibodies in the body.

There are other studies that document asymptomatic cases reporting back with heart and lung complications months after getting treated for COVID-19. Yet another study states that children carry more virus in the nasopharynx and may be more potent carriers than adults. Yet another study says less cases among children may be due to low community spread due to school closure. The fact remains that this is a new disease and we still do not know much about it. This madness of studies will continue till we start to get a clearer picture of the novel coronavirus. However, there is danger in increased knowledge too as mentioned in the famous expression, “Familiarity breeds contempt”.

This is already evident with the emergence of a group of people who are being termed as ‘covidiots’. These people remain in denial of the seriousness of the novel coronavirus. They dismiss it with arguments such as “It’s just a flu…”. many of them believe that they will get infected sooner or later and argue that it’s good to get infected. Common sense, and our knowledge of public health suggests that it is more prudent to take precautions till a safe and effective vaccine is available for everyone or the pandemic ebbs. I see the latter happening sooner as the emphasis for the vaccine is on being ‘safe’ and ‘effective’, which typically goes through five stages of development and normally takes around five to 10 years.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

An opportunistic virus

Very few children seem to be getting infected by the new coronavirus and even fewer are actually getting sick from it. Having watched its progress through treating patients with a wide range of severity of symptoms, I have reached a fairly simple conclusion. The new coronavirus is a mean and opportunistic virus. It is like a bully that oppresses the weak and vulnerable. It’s constantly on the lookout for victims that it can overpower. It cannot harm or at least does not seem capable of harming a person with a strong constitution. A healthy person may not even realise that the virus has invaded his or her body. However, the virus uses healthy people as a way to infect others who might be weaker and more vulnerable. This is a classic trait of an opportunist! It preys and harms the weak and spares the strong. This reminds me of the Ladakhi proverb, “Nyam chung nga Shig ge tsod chad” (Even lice will bully a docile person).

I will admit that I was happy in the initial days when it was believed that children might be immune to this virus. It was seen that among all cases of this new disease, only 1% or less were below 18 years of age. This was a relief to most parents, including me. While this still seems to be true to a large extent, children have started showing a diversity of symptoms caused by novel coronavirus besides regular cough and fever.

One of our recent patients is a 14-year-old boy. It seems perhaps coronavirus was too weak to overpower him earlier or the boy was too strong for this opportunistic virus. Perhaps the virus has been lingering around him for some time but could not harm in any way. The boy probably took all precautions including wearing a mask and washing his hands frequently. And yet, he was to soon become infected by this mean virus.

The boy met with an accident when he fell from a tree while playing. The resulting injury confined him to a bed for a few weeks and weakened him. This served as an opportunity for coronavirus and it managed to overpower his otherwise strong immune system. He developed a very severe form of the disease. Think there are many lessons here for us to ensure that we are healthy, fit, and strong at all times.

However, I cannot help but wonder if the coronavirus is not worried about its own survival if it continues to harm its victims. Every creature, including humans and plants, are constantly trying to increase their population. However, nature always has system of checks and balances. For instance, human action causes a decline in bird population, which in turn results in an increase in insect population that will decrease the yield of human farms! This leads to major social, economic and environmental challenges. Nature does not favour anyone and has systems to check all forms of excesses.

So, what will happen to coronavirus? Nature will not tolerate the havoc caused by this virus. It will increase human capacity to counter this opportunistic virus by modifying our immune system by producing immunoglobins. We have seen this happen countless times in the history of all living creatures on the plant. Nature teaches us and we have to learn. Perhaps, this time we will work in sync with nature to live healthier lives and respect the environment. In turn, we will be able to develop a vaccine to help our body strengthen its defences before the virus invades it.

As of now, it the most important thing we need to do is protect high risk individuals who have a weaker immune system that makes them vulnerable to the ravages of this virus. At the same time, we all must adopt healthy lifestyle habits in terms of our diets, give up addictions (smoking, alcohol etc) exercise regularly, which will hold us in good stead even beyond the current pandemic.

As for our 14-year-old patient, he has turned out to be rather brave. He seems to be emerging from the disease through his mental and physical strength. I have witnessed him counter the bully. He is currently recuperating well and waiting for the results of his test that will tell him if the opportunistic virus has left his body.

By Dr Spalchen Gonbo

Dr Spalchen Gonbo is a Paediatrician based in Leh.

Managing neighbours

Having a good neighbour is a blessing. It’s always useful to have a neighbour. Getting to know one’s neighbour comes with a wide range of benefits including enhanced safety, shared sense of community, mutual sense of responsibility, lifelong friendships and a helping hand nearby. Whether one needs to borrow some sugar or needs some emotional support, a good neighbour is always there to help. This is because they are in close physical proximity in times when even a close relative or a dear friend living at a distance may not be of much help.

Sometimes, even a bad neighbour can be more helpful than a relative who lives some distance away! There is a wise Ladakhi proverb that should give us much to think about. It goes, “Thag-ring nge nyen sang khim-tses se gra gyal” (A bad neighbour is better than relatives who live far away). These words of wisdom not only apply to individuals and families but also to countries.

We are supposed to be living in the most peaceful era in the history of humankind. It is a time when war has become uncommon, famines are rare and epidemics were considered to be impossible as progress in science meant that any disease could be treated. Humans are on the brink of overcoming the concept of mortality and may even achieve immortality. It is said very soon humans will be able to overcome aging and then find ways to live as long as one wants. Science promises to reduce age to a number. At the same time, sickness and diseases will be rare and humans will only die in accidents or through fatal injuries.

Many philosophers are of the opinion that war will become very rare as humanity has come to realise that it does not solve any problem. Instead, it only leads to suffering, death and destruction and in the end, there are no winners or losers. In the past, war has been fought over ego, territorial gain and natural resources like forest and oil. Most civilised societies have now learnt that natural resources are something to be conserved rather than exploited. At the same time, we have created alternate renewable energy sources that have made us less dependent on oil and gas. We now have the technology wherein a car can run for a year on a litre of water, rechargeable batteries or solar energy. Other causes for war include gold, diamond and other such resources, which we are now able to produce in laboratories. So, war seems to have become redundant!

India has always been a peace-loving country. It is a country that has always been concerned about the welfare of its citizens. It is a country where people have a voice, the freedom to express their views, to disagree and to question each other and the government. It is a country where the voices of people are heard. It is the world’s largest democracy where people regularly exercise their freedom and right to elect people to form a government.

India is a welfare state and its citizens enjoy a wide range of freedom and rights unlike many of our neighbours. India’s friendly attitude towards its neighbours and its yearning for peaceful relations has often been interpreted by them as a sign of weakness. We have been provoked a number of times into war by our neighbours but each time we have managed to teach them a lesson. I wish that we are able to improve our relations with ‘bad’ neighbours like China and Pakistan and resolve our differences. And this is not only my view as a citizen of India but also an emerging global consensus that a change in the attitudes of our neighbours will help improve these relationships. In my opinion, it’s better to improve our relationship with neighbours like China and Pakistan instead of concentrating solely on friendships with distant countries like the USA. All of us must learn from the example of countries that are actively working on resolving their differences and working on uniting rather than disintegrating.

That said sometimes small arguments and fights are necessary to resolve issues or teach a lesson to an annoying neighbour so that they learn a lesson in their own language. In psychological terms, this is called ‘mirroring your neighbour’s behaviour’. They should learn that a war with India will be very costly and that it will bring destruction to both sides. I hope and pray that the heroic fight and sacrifices by our soldiers in the Galwan valley goes a long way in improving our relation with our neighbours and a spirit of friendship prevails in our general neighbourhood!

By Dr. Spalchen Gonbo

Dr. Spalchen Gonbo is a Paediatrician based in Leh.

Photograph by Tsering Stobdan