Are we living or are we dying?
Both are true! Same as a glass of water can be half full or half empty.
In an increasingly uncertain life, two things are certain, first is that we are born and second is that we will die. Events in between are uncertain.

We all have an expiry date written somewhere but luckily we don’t know where and we cannot decipher it!
Suppose we could decipher it and know our date with fate, everything would become pointless. Our attitude would change completely from the enthusiasm of living and planning for the future to a feeling of futility because the future does not exist post expiry date!

In Tamil Nadu and Kerala there is a form of astrology called Nadi. It is based on the belief that the past, present and future lives of all humans were foreseen by Dharma sages in ancient times. The first sage being Agastya. This was written on palm leaves and stored for reference in the Vaitheeswara Temple in Sirkazhi, Tamil Nadu. A person’s leaf could be retrieved by the astrologer based on the date and time of birth and it could accurately tell you the day of your demise. One of my friends recalls that his brother went to a Nadi astrologer, who accurately told him his parent’s name and other details then was just about to reveal his date of demise when he silenced the astrologer mid sentence. He wisely didn’t want to know! If he was told the date, that knowledge would hang over his head like the sword of Damocles. He would count the days, the hours, the minutes and finally the seconds to the day and then it may turn out to be a damp squib! An example is of the Mayan Calendar which experts said predicted the end of the world in December 2012, because the calendar ended on that date. Considering the world is still around in 2020, it was a total wrong presumption! However a lot of people spent anxious moments anticipating the end of the world.

Scientist say “whether the earth will end” is not the question, the question is when the earth will end?”. The end may come as a meteor hitting the earth or a large solar flare destroying the ionosphere and exposing us to cosmic radiation or eruption of a supervolcanoe causing an ash cloud to block sunlight or even the Halydron collider which is trying to recreate the ‘Big Bang’ in miniature exploding.

Quoting the Bard of Avon, William Shakespeare, “A coward dies a thousand times before his death, but the valiant taste of death but once. It seems to me most strange that men should fear, seeing that death, a necessary end, will come when it will come.”

As I gradually creep toward senior citizen status many of my contemporaries have abandoned me. Some due to disease and others due to accidents. The incident which really shook me to the core was the passing away of a MBBS classmate, room mate, friend, philosopher guide and teacher, Sunil Agarwal. He died in an unfortunate car accident, this February 2020 and just before embarking on the fatal last journey, he messaged me good morning and that he was going to a mission hospital for a camp and that he was looking forwards to the cool weather there. Little did I know that by evening I would hear about his demise.

An analogy of life is a train journey. You boarded when you were born and on the way lots of passengers boarded and shared a part of the journey with you, only to disembark at some point for a different destination or sometimes permanently like Sunil.

I try to empathize with the cancer survivors who have been operated, received chemotherapy and radiotherapy. Now they can only wait or better live. The disease may raise it’s ugly head again. All it requires is one single cancer cell remaining, which can multiply rapidly and overwhelm their body. They could be in an pessimistic frame of mind or an optimistic frame of mind. In former they are dying a thousand deaths, whereas in the latter they die only once.

Legend has it that the ancient Gauls who inhabited present day France only feared the sky falling on their heads. The SARS COV-2 pandemic, has brought us to a similar predicament. Shoving our own mortality, right into our face. Suddenly we are faced with the real possibility that we may be infected and our infection may be severe enough that we may die!
One question is on everyones mind, “मेरा number कब आएगा?” or “when will my time come” and this is not with hopeful anticipation but with dread.

The virus is highly infective and a zoonotic infection or one which has jumped from animals into man following a crucial mutation which allowed it to infect humans. There is the conspiracy theory that it was genetically engineered to make that jump, blaming our neighbours to the east. But we won’t go into that!
This is not the only virus which is zoonotic, earlier we had swine flu, chicken flu, MERS and SARS which also belong to the same family of Corona viruses, so called because they have a halo or crown or crown surrounding it. These did cause their share of deaths but are not as infective as the latest avatar of corona, SARS COV-2.

Then there is the famous human immunodeficiency virus, which causes the acquired immunodeficiency syndrome or AIDS. The virus belongs to a family of retroviruses and is also a zoonotic infection. It was supposed to have jumped from the African green monkey into humans.
Arthur Ashe, the African American tennis player who is the only black player to have won Wimbledon, American open and Australian open contacted AIDS from blood transfusion following heart surgery. One of his fans wrote him a letter and asked, “Why does God have to select you for such a bad disease?”
His answer was, “The world over — 50 million children start playing tennis, 5 million learn to play tennis,
500,000 learn professional tennis, 50,000 come to the circuit, 5000 reach the grand slam,
50 reach Wimbledon, 4 to semi final, 2 to the finals,
when I was holding a cup I never asked GOD ‘Why me?’.
And today in pain I should not be asking GOD ‘Why me?’ ”
Happiness keeps you Sweet,
Trials keep you Strong,
Sorrow keeps you Human,
Failure keeps you humble and Success keeps you glowing, but only Faith & Attitude Keeps you going.”

Quoting Oscar Wilde, “To live is the rarest thing in the world. Most people exist, that is all.”
I see lot of my colleagues hiding in their homes and avoiding contact with patients in fear that they will contract the disease. However how long can you hide! The virus is going nowhere and our redemption lies in herd immunity or invention of an effective vaccine. Herd immunity will only kick in when at least 60% of the population is infected and as for the vaccine, attempts to create a vaccine for the other corona viruses also yielded zilch. This was thanks to the virus’s penchant for mutations, making it difficult for the antibodies to recognize the mutated virus.
However recently I read that the virus in it’s current mutation causes a less severe disease. This is also a self preservation strategy of the virus. If it killed all it’s host rapidly, it would no longer be able to spread and infect new hosts. Simply put all the people infected with the severe form of the virus succumbed to the infection ending the life cycle of the virus with them. However it is the ones with less virulent strains, who remained asymptomatic or only had mild symptoms, who spread it to others. Therefore the milder versions of the virus get disseminated while the virulent die with their host.

It has been predicted by an epidemiologist that COVID-19 will kill at least 2 million people in India. Though the number sounds large, so is the population of India at 1.3 billion. If you do the simple mathematics, 2 million merely represents 0.15% of the population of India, reducing the probability of you being part of this statistic to lower than the chances of you winning a lottery ticket. Have any of you won a lottery?

Since our knowledge of this virus is merely 6 months old we are daily learning new facts about it. The chances of contacting it while touching inanimate objects or fomites is low. The highest incidence of transmission is through aerosol or tiny droplets of saliva and mucus which are emitted when we cough or sneeze. These droplets when inhaled can enter the respiratory system via the trachea then bronchi, bronchioles which finally end in a tiny sac like unit called the alveolus. The respiratory system brings air into the alveoli, the lining is rich in blood vessels and exchange of gases occur. Oxygen diffuses into the blood and carbon dioxide comes into the alveoli which is exhaled. But now with the air also comes the virus and causes an inflammation in the alveoli, affecting the gas exchange. It also causes what is famously known as the cytokine storm, an over reaction of the body’s immune system to the virus. This causes irreversible destruction to the alveoli giving rise to a reduced lung function. The destruction could be so extensive that no alveoli is left for gas exchange.

The use of ventilators in these patients is push oxygen with pressure into the lungs, inflating all the alveoli and improving gas exchange. However now with no functional lung tissue left, pushing oxygen serves no purpose. Only an Extracorporeal Membrane Oxygenation ECMO, will work. This is similar to the heart lung machine used during cardiac surgeries. The blood is diverted to the machine and it oxgenates it and pumps it back, giving the heart and lung rest. But for a completely destroyed lung only option is a lung transplant.

The strategies which are being used for treatment are transfusing the plasma of patients who have recovered from the infection. Their plasma is rich in antibodies against the virus and help in fighting the virus. Antiviral like Remdesivir show promise in fighting the virus. A steroid like Dexamethasone which suppresses the immune response of the body is helpful in reducing the damage caused by a cytokine storm.
There is a race to make a vaccine for this virus spurred both by concern and commercial considerations. However the vaccine may not be effective because the frequent mutations the virus makes.

The virus is here to stay and we have to learn to co-exist with it like we learnt with other viruses. We cannot hide away forever and have to resume a new normal life which include the necessary precautions.
Finally we have to live and not exist or die a thousand deaths.