We forget the story at our own risk.
In the 1980s, more than two lakh newborn babies died each year in India from a dreaded infection. This, when that preventable disease was only of academic interest in the developed world. WHO and the Indian government have worked together to address the factors that lead to disproportionately high rates of this infection and neonatal fatalities in India compared to the rest of the world. These efforts paid considerable dividends: in 2015, India announced that the country had successfully eliminated the disease.
The condition referred to is neonatal tetanus. Caused by bacteria that are present all around us, especially in soil and animal manure – in India and the rest of the world. But what caused the disproportionately high number of infections in India? Studies have identified that low vaccination rates in India, together with high rates of home births under unsanitary conditions, are the predominant causes. In relation to the latter, the presence of cow dung in the vicinity of calving – especially the application of cow/goat dung to the newborn’s umbilical cord stump was identified as a major factor. The reason: the abundant presence of tetanus spores in animal manure.
Fast forward to 2021:
The devastating effects of the COVID-19 pandemic in India were exponentially exacerbated by a bewildering explosion of cases of mucormycosis (black fungus). India has an alarmingly disproportionate number of this comparatively rare infection – a colossal one 71% of all global cases in Covid patients even before the devastating second wave – significantly higher than even in our subcontinental neighbors. What is it about India that explains these high numbers? This hypothesis struggles with the question and ultimately postulates that cow droppings are an important factor – that during this COVID wave, cow droppings, steroids, diabetes and untested drugs collided to create the perfect storm of mucormycosis in India.
My conclusions are drawn from the following facts and assumptions:
- Cow droppings are rich in spores of Mucormycetes, the fungus that causes mucormycosis. In its inactive form, the fungus is widespread, present everywhere around us in the form of spores. Spores allow the fungus to survive adverse conditions and disperse, and then grow and reproduce when conditions are right – similar to seeds in the plant kingdom. But, notably, these fungi have a particular affinity for dung from herbivores (grass-eating animals) and are called “coprophile fungi”, which means “dung-loving fungi”. (see Section 3.3 of it is Publication.)
- There is a long tradition in large parts of India of incorporating cow droppings in multiple facets of daily life – significantly and disproportionately more than in most other parts of the world. Examples include applying cow dung to bodies, soaking cow urine, and using cow dung for fuel and shelter. Panchagavya, for example, taken as an Ayurvedic medicine by many Indians, contains cow dung, cow urine, milk, butter and curds. Naturally, any population that engages in such practices will harbor a large load of mucus spores in their bodies and environment.
- To reinforce the above point, it is important to note that the personal use of cow droppings among the Indians greatly increased during the COVID pandemic. Under the patronage of political and religious leaders, many Indians actively used cow dung and urine regularly and in large quantities, in the hope of preventing and treating COVID, despite warnings from the scientific community. This possibly paved the way for unusually large fungal loads and, syllogistically, atypical and markedly high chances of systemic fungal infections among Indians.
- Fungal spores, although present in the soil and around humans, decaying matter, compost, dung, animal excrement and bird feces, generally do not cause systemic diseases as they are opportunistic pathogens. These pathogens normally lie dormant within a host and cause disease only when circumstances are ripe for their proliferation. One such favorable circumstance is an immunocompromised host, a patient whose immune system is weakened for a variety of reasons, including infections such as COVID, diseases such as cancer, or the use of immunity-suppressing drugs such as steroids (technically called glucocorticoids. Examples of commonly used steroids in medications include dexamethasone, prednisone, budesonide and hydrocortisone). This immunocompromised patient is significantly vulnerable to the development of a systemic fungal infection.
- Steroids are among the most important medications used in the medical treatment of advanced Covid. COVID infection can cause a disordered inflammatory response in the body, called a cytokine storm, which can lead to significant organ damage, including serious damage to the lungs. This can cause patients to become breathless and require supplemental oxygen and sometimes assisted ventilation. So, paradoxically, the body’s immune system (which is normally critical to preventing infections) in this case actually harms the body through this inflammatory response. Therefore, in the treatment of COVID, steroids are commonly used when signs of inflammation are present clinically and also as evidenced by specialized blood tests, in order to suppress the harmful immune reaction. Thus, the patient, with the immune system already weakened by Coronavirus infection, becomes even more vulnerable to the development of a systemic fungal infection.
- Anecdotal reports suggest that there was overuse of steroids in the treatment of COVID in India: making patients particularly vulnerable to systemic fungal infections.
- Another favorable circumstance for fungal proliferation – and therefore systemic fungal infection – is high blood sugar levels in the patient, as in diabetics, especially those with uncontrolled diabetes. India has a huge number of diabetes cases spanning the spectrum of blood sugar levels – controlled, uncontrolled and poorly controlled. Many patients with diabetes in India are still undiagnosed.
- As part of its biochemical actions, steroids raise blood sugar levels opposing the action of insulin and stimulating the production of glucose in the liver. This can lead to massive increases in blood sugar levels, especially in diabetic patients, which, in turn, can make the patient more vulnerable to systemic fungal infections.
So, in our context, we could say that for a fungal infection to happen, there must be:
- Presence of fungal spores, ideally in conjunction with:
- Presence of an immunocompromised patient,
- And/or the presence of a patient with diabetes/uncontrolled sugar levels.
In short, the following overlapping elements came together to create the Perfect conditions for systemic fungal infections in India in recent months:
- Generous and widespread use of cow dung and urine, providing large loads of fungal spores, within, over and around the vulnerable population. Just as a baby whose umbilical cord stump was stained with tetanus-rich cow dung was at a disproportionately greater risk of developing neonatal tetanus than one who was not subjected to this ritual, the Indians who actively bathed, ingested, drank, breathed or Cow dung and urine rich in Mucor spores applied topically run, according to any epidemiological logic, a disproportionately higher risk of developing mucormycosis.
- Steroid treatment of COVID (particularly if it is more than the recommended dose), increasing the risk of immune suppression and therefore infection by opportunistic mucous spores in the already vulnerable COVID patient.
- Steroids also cause elevated blood sugar levels, especially among diabetics, adding another risk factor for systemic fungal infection to the mix. In such a scenario, diabetics – already a well-known demographic group at high risk for Covid’s complications – bearing the brunt of Mucormycosis infections is no surprise.
- 2-Deoxy D-Glucose is used exclusively in India for the treatment of COVID. Although some reports suggest it has the potential to cause blood sugar to rise, further studies are needed to confirm these findings.
- Coronil, widely used in India as an “alternative/prophylactic cure” for COVID, has been marketed in various ways as an “immunity booster”, an “herbal supplement” and a drug that “may kill the coronavirus”. It is supposed to be an immunomodulatory and anti-inflammatory agent – in other words, its actions are similar to those of steroids. Does this mean that you can “clandestinely” increase the dose of steroid given to patients? Do herbal constituents have unknown side effects? We certainly need more information about this drug so widely used during this critical period. O “Research Article” supplied by the manufacturers, Patanjali, is not peer-reviewed and its claims are dubious at best. Likewise, the potential presence of steroid-like components and/or cow droppings in various other indigenous remedies used in India cannot be excluded without further studies.
To return, once again, to the critical issue of fungal spores: as experts and journalists gleefully ramble on the role of steroids and diabetes – and even iron, zinc and the Delta strain variant – to disproportionately high rates of mucormycosis cases in India, they are completely, unabashedly silent about the origin of the fungal spores that seem to be so abundant around these patients.
Here’s the crux: without the spores, there will be no fungal infection – even in the most immunocompromised patient or the most out-of-control diabetic.
And a large number of Indian patients have been exposed to an extremely high load of Mucor spores through the intimate use of cow droppings – this is an undeniable fact.
Consider this presence of abundant and widespread fungal spores in the vicinity of Covid, immunocompromised, devastated, steroid-treated Indian patients who probably also have high blood sugar levels – and we have a pretty complete picture explaining the possible reason behind the disproportionate number high of mucormycosis cases in India. (Further research on Coronil and 2-DG could further clarify the situation.)
Important corroborative evidence is the case distribution within India itself: cases are highest in states likely to use cow droppings extensively, such as Gujarat, Maharashtra and Andhra Pradesh, while relatively lower in states likely to abstain from such practices, such as Kerala and West Bengal .
To summarize, we need to focus on these two unique Indian factors to solve the mystery of the number of unique cases of mucormycosis in India:
- The widespread use by Indians – especially during the Covid pandemic – of cow droppings (dung and urine) which we know harbor mucus spores, thus exposing vulnerable, immunocompromised and diabetic patients to heavy loads of the fungus in their immediate environment.
- The widespread use by Indians of untested and poorly tested drugs, such as Coronil and 2-DG, can increase immunosuppression and raise blood sugar levels, thus increasing their susceptibility to fungal infections.
To be absolutely clear, this is just a hypothesis, and detailed research is needed to conclusively prove or disprove it. Studies that examine these and other factors in depth will undoubtedly benefit current and future patients – and that should certainly be our ultimate goal.
But the problem here is that detailed research takes time – time that patients suffering from this debilitating disease now don’t have. (we have already crossed 31,000 cases and 2,100 deaths!) It is therefore the responsibility of the medical community in India to ask pertinent questions, carry out informal cause-effect analyzes and in the meantime send strong medical advice to the public to stop all practices that are not globally, scientifically approved, as we fight against the dual crises of the COVID pandemic and endemic mucormycosis. Until this clear message reaches all Indians, we will be failing in our duties as doctors, scientists and leaders. I sincerely hope that we learn from the lessons of our past, that common sense prevails, and that further loss of life—due to a potentially preventable condition—is avoided. Learning from the successful model used in neonatal tetanus elimination can go a long way towards achieving this goal.
Dr. Jessy Skaria is a doctor