Dr. Arvind Kumar is a founding member of the Lung Care Foundation; Chairman, Centre of Chest Surgery; and Director, Institute of Robotic Surgery, Sir Ganga Ram Hospital. He holds the following degrees: MBBS (AIIMS), MS (Surgery, AIIMS), MNAMS, FACS (USA), FICS (USA), and FUICC (Geneva). He is also the recipient of the prestigious Dr. B.C. Roy Award for Eminent Medical Person for the year 2014. He is currently in the frontline of the battle against Covid-19. In this interview, Devadeep Chowdhury discusses pertinent questions that we face during this time.
Q: Covid-19 poses a set of unique medical challenges. As per your experience, are Indians who are exposed to chronic air pollution more at risk of fatality due to Covid-19’s effect on the lungs?
A: As far as Indian data is concerned, the strongest evidence of a correlation between pre-existing lung diseases and death due to Covid-19 has come from the city of Bhopal. Over ten patients have died in Bhopal till now and all of them have been victims of the Bhopal Gas Leak. They have suffered from lung diseases following gas inhalation.
See, the correlation between factor A and factor B, if you sought to decipher it, would need a very different kind of study. However, almost all these studies have definitely established that the pre-existence of lung disease is a risk factor for death due to Covid-19, whether that lung disease comes from smoking, air pollution, or inhalation of gas as in the case of Bhopal. So, the ultimate endpoint is lung damage, and a diseased lung is more prone to succumb to the novel Coronavirus.
There is no point asking whether air pollution damages the lungs or not – it is proven that it damages the lungs as much as smoking. So putting these things two things together, there is no hesitation in saying that people who have had lung damage as a result of pollution will have a higher mortality rate related to Covid-19. Now, getting clear cut data from our country would take some time or may not even come out, the reason being that these deaths are occurring in a vast geographical area.
Now if you have to prove the air pollution-related Covid-19 deaths, you have to conduct a study like Harvard University did in the US. They looked at deaths in 3000 odd counties and they correlated those deaths with the pollution levels of those counties. They proved that for every microgram rise of PM 2.5, there is a demonstrable increase in the mortality rate, with all other factors excluded or remaining the same. Similar data has come out of Italy. Within Italy, there are two sets of samples – from the north and the south. North Italy is a highly polluted area while South Italy is comparatively less polluted. PM 2.5 levels are particularly high in North Italy, especially in a county called Bergamo, which has almost India-like figures of PM 2.5. When they examined the rate of spread of Covid-19 as well as the mortality rate, both were found to be much higher in this Bergamo county and surrounding areas compared to South Italy. The explanation they gave was the virus may be latching onto the PM 2.5 particle surface, and that is helping it in dissemination through ingestion in lungs and staying there. They demonstrated a higher transmission rate, and once transmitted, higher mortality. So, these two distinct international pieces of evidence establish that pollution-affected communities are a weak spot for Covid-19 deaths.
Q: Given that people have lived amidst chronic pollution, what is your suggestion for precautions for a large section of the vulnerable population who might have a variety of lung ailments and may contract the novel Coronavirus?
A: Let us look at what constitutes pre-existing lung diseases. The most common ailment is asthma. One segment of the population has well-controlled asthma wherein just using inhalers is enough and they should continue that. But patients who need to take oral steroids to control their asthma are not only at a higher risk of infection but also face an increased threat of death. Second is COPD (Chronic Obstructive Pulmonary Disease), in which your lungs are permanently damaged. These people are at a higher risk of both getting the disease and dying from it. Then you have pneumonia. Initially, it was thought that Covid-19 causes pneumonia, but we are finding that it is not pneumonia but something else that is happening to the lungs in Covid-19. People with pneumonia can also get Covid-19 at any point in time as pneumonia itself is highly infectious and leaves you vulnerable and at high-risk. Finally, there is a big group of people with something called interstitial lung disease in which the lungs get very stiff. These people are often on steroids that can reduce their immunity. Their lung capacity is also reduced, so if they get Covid-19, their mortality rate is higher. Similarly, patients of tuberculosis, current or previous, who have had big parts of their lungs destroyed, are also at increased risk.
So what precautions can be taken? Firstly, keep your present diseases under control as advised by your physician. Secondly, take steps to improve your immunity in general, i.e., no stress, no smoking, avoid excessive drinking, eat regularly but don’t overeat, exercise inside your house, etc. Another really beneficial thing is practicing yogic exercises such as anulom vilom, kapalbhati, and bhramari. Various yoga experts have been repeatedly demonstrating them on TV. Take my word, these are excellent exercises for improving your lung capacity and will definitely increase your capacity to fight these diseases.
The specific measure they need to take is what the entire country is doing and doubling down on it. Three cardinal rules: washing hands vigorously, use of face cover when going out (but avoid leaving home as much as one can), and social distancing even from family members need to be strictly adhered to by all patients of pre-existing lung diseases. If you stay away from people, the virus can’t reach you.
Q: Some reports from China suggest that recovered Covid-19 patients have developed permanent lung damage. Can you explain how that happens?
A: This is not the first time this has been observed. Permanent lung damage happened among recovered patients during the SARS outbreak as well. Depending on the severity of the disease, patients have variable recovery and varying long term consequences on their lungs. Out of those who recover, many return to normal, but some develop a permanent deficit in the form of reduced lung capacity. Now the amount of this deficit can vary from mild to crippling. This may unfold in Covid-19 cases too. The majority of the people say 85%, will have a mild infection. The rest 10-15%, who will have a severe disease that involves hospitalization and ventilator support, may develop permanent complications. How much of it happens in the case of the Covid-19 outbreak will probably unfold in the months to come.
Q: In terms of treatment of Covid-19, can there be any new methods such as thoracic surgery?
A: No, this is a systemic disease. The pathology of lung involvement isn’t directly by the virus but something that was caused by the virus. The general word we are using today is cytokine storm, i.e., a defense mechanism mounted by the body against the virus. But it mounts to such an extent that the defense mechanism actually ends up destroying the body or the organs. In that situation, surgery doesn’t play a role.
Q: Are you hopeful about the recent plasma therapy treatments that are being tried?
A: Plasma therapy is nothing new. It was used about a hundred years ago against diphtheria, and the gentleman who invented it, Emil von Behring, won a Nobel Prize for it. In plasma therapy, you take blood and plasma from a patient who has recovered from the disease. So, when someone recovers, the body produces antibodies, and it is expected that these antibodies can kill the virus in a diseased patient’s body. But there are some assumptions involved here. Number one, the donor’s body has adequate levels of antibodies. Number two, these antibodies can kill the virus. Lastly, from the time of injecting the antibodies to a recipient’s body, the killing of the virus will arrest the process of deterioration.
Now, if that person doesn’t have adequate antibodies, it will go to waste. If the antibodies are not the fighting type, it won’t help. The antibodies may kill the virus, but the chain of reaction initiated by the virus continues nonetheless, so destroying the virus doesn’t help. The flip side is that an unknown plasma infusion can lead to other infections. Therefore, the current status, as articulated by the Ministry of Health, and one I agree with, is that this is an investigative therapy and must only be initiated as part of a clinical trial after taking approval of the ICMR where all actions are strictly controlled, monitored, and analyzed.
Q: You are the founding member of the Lung Care Foundation. Please give us a little glimpse into its roles.
A: The Lung Care Foundation is completely devoted to the care and cure of patients with lung diseases. As a surgeon, Covid-19 doesn’t come directly under my repertoire. However, since we are devoted to lung care, and the lung is the most common organ affected by the Coronavirus, we are involved. Air pollution is also impacting the outcomes badly. One thing that this outbreak, and the resultant lockdown, has shown us is that, contrary to popular belief, we can clean our air. The only thing that is required is political and popular will. We just need to understand that air pollution and climate change are as equally serious and deadly as the Coronavirus.