The record high number of new COVID-19 cases being reported in Delhi is a “direct effect of air pollution”, says Arvind Kumar, chairperson, Centre for Chest Surgery at Sir Gangaram Hospital (SGRH), New Delhi.
Virus particles piggyback on particulate matter in the air, and enter the lungs, Kumar explains, adding that pollution is also related to heart disease, hypertension, etc., all of which increase the risk of mortality from COVID-19.
“If this deadly cocktail--the festivities which will occur over the next few days, coupled with the steep rise in pollution--has an effect on COVID and we see a massive spike, it will be disastrous for the people as well as for the healthcare sector because the ICUs are almost choked, at least in all Delhi hospitals,” Kumar says, emphasising the need to wear masks, maintain physical distance and practice hand hygiene, in addition to doing everything we can to reduce pollution.
Kumar is also the director of the Institute of Robotic Surgery at the SGRH, and founder of the Lung Care Foundation.
In our earlier conversation, you had correlated higher deaths in parts of Italy with pollution. What was it like then, and what are we seeing today in Delhi and potentially in other parts of the country where pollution levels are rising? What is common between the two?
What I had said back then is now being seen in Delhi. At the time, I had quoted a study from Italy, which had correlated the incidence of COVID-19 cases with PM 2.5 levels across Italy. [PM 2.5 refers to airborne particles 30 times finer than a human hair that can sicken or kill people by entering the lungs.] When they plotted heat maps of COVID-19 cases and PM 2.5, they found the two maps to be replicas of each other--areas with higher concentration of PM 2.5 reported a much higher incidence of COVID-19 cases per 100,000 population.
A couple of months later came another report from Harvard, which looked at the mortality correlating to PM 2.5: For every 1 microgram rise in chronic PM 2.5 exposure, they noted an 8% increase in mortality. This was pooled data from over 3,000 counties in the US.
This was evidence that COVID is increasing in incidence and causing more mortality in communities that are affected by pollution. And now, what we are seeing for the last two weeks in Delhi has confirmed that. Till a few weeks back, there was a decline in the number of cases across the country and also in Delhi. But as soon as there was a spike in pollution levels in Delhi, the decline converted into a steep incline, and today we are seeing the highest number of cases per day being reported in the city. This is directly an effect of air pollution.
Why do COVID-19 cases rise specifically at a time like this, assuming all other factors are constant?
There are many theories. One is that the virus particle piggybacks on the PM 2.5 [particle]; it gets adsorbed on the surface of PM 2.5 and when we inhale a large number of particles adsorbed on their surface, the virus particle also goes deep down into the chest, thereby increasing the total dose delivered and total duration for which the virus stays there. But that is not the only cause.
We know that pollution badly affects the lungs. It causes inflammation of the lining of the windpipe and lungs, which reduces their immunity and increases their vulnerability to infection. When you have an injured and inflamed lung and you have a certain dose of virus entering into the lung, that injured, inflamed lung will be more prone to infection than a healthy lung. [This is] common sense.
Plus, these people may otherwise also have low immunity because of various other toxins which go in the pollution. So overall, you have low body immunity, low lung immunity, and on top of that, you have the same dose of virus going. I think it proves to be the crucial dose that converts into clinical infection.
This was about the high incidence. Now, why do we have higher mortality?
It has been proved that people who have higher incidence of heart disease, hypertension, lung problems, low immunity and all other problems have a higher chance of mortality when they contract COVID-19. This is a link that has been established across the world. These are exactly the diseases or problems caused by pollution. So when you have a pollution-affected community, they would have lungs affected, higher incidence of hypertension, heart disease, brain attack--all these problems that increase the mortality. So, these people are more prone to get the disease and more prone to death if they get the disease.
Does this also mean that people are not taking sufficient care? For instance, if people were to continue to wear good quality masks or N95--which was originally meant for pollution--is it not a sufficient guard or barrier against both pollution and the virus?
There are two aspects. First is the prevention of COVID, for which we know there are three golden principles: wearing a mask, social distancing and hand hygiene. If we say goodbye to any of these three, we are increasing our dose exposure and therefore the chances of getting COVID.
On top of that, if I am also affected by the effects of pollution, and also ignore precautions for COVID, then my chances of getting COVID are increased that many times.
Therefore, wearing masks will prevent us from getting COVID-19, and will also have protection against pollution. So it becomes mandatory for all us to wear masks, keep social distance and practice hand hygiene, and along with that, also do everything possible to reduce the level of air pollution.
What do these levels of air pollution--an air quality index (AQI) of 400, classified as moderate to severe air pollution--do to the body? What are the other problems that it causes typically?
We breathe 25,000 times a day, we inhale nearly 10,000 litres of air in 24 hours. Children breathe much faster, and per body surface area, they inhale much more air than adults do. When you have these huge amounts of toxins--whether it is particulate matter or toxic gases--going inside the body, the first thing that they damage is our nose, our respiratory tract, and our lungs. But the story does not end there.
Most of these chemicals, whether it is PM 2.5 or the gases, cross the lung lining, enter the blood and through the blood, they go into every organ that gets blood--from brain to bones to every part of the body. And they cause damage. The worst affected are pregnant women. It has been proved that this damage actually starts from the intrauterine line.
For all the pregnant women who are inhaling this toxic air, there is some amount of damage occurring to the baby being nurtured in their uterus. When the baby comes out and takes his or her first breath, if you have PM 2.5 which is close to 500-600 [AQI]--equal to about 30 cigarettes of smoke in terms of damage--your newborn becomes a smoker from the first breath of his life. Imagine the amount of damage that will occur to his lungs and other parts of his body. Similarly, this continues through your childhood and adulthood. In the elderly again, their immunity is reduced. So the worst affected are the children, the elderly and pregnant women. But nobody escapes the ill effects. The only way you can escape the ill effect is if you stop breathing.
Are the solutions to the twin problems of COVID-19 and high air pollution the same--wearing a mask etc.? I guess you cannot distance yourself from pollution but you can stay at home, have air purifiers--what do you do?
The immediate measure is we must continue to practice the three golden principles for COVID-19 prevention--never ever go out of your house without a mask, always practise social distancing, [and practice hand hygiene]. I give a very simple rule: Please presume everybody to be COVID-19 positive. Keep 1.5-2 metres distance from everybody. And insist on everyone around you wearing a mask. If the other persons are wearing a mask, especially if it is N95, and you are also wearing a good quality mask, and you maintain 1.5-2 metres distance, even if one of them is positive, the chances of transmission are drastically reduced. And presume every surface and every article you touch to be positive and practice hand hygiene.
On pollution, whatever is the preventable part of the pollution, whatever little contribution is coming from our streets, our garbage burning and other sources that us citizens can control by our little actions, we must do so immediately. The N95 mask or any other mask that we are wearing will give whatever little protection it can for pollution. But mind you, the gases cannot be stopped by any mask. So, we need to work on reducing the pollution. We cannot presume that an air purifier or mask will give us all the protection. We are recommending air purifiers for lung patients, little children, people who are having disease, and post-COVID patients.
Post-COVID patients are facing a very serious problem because they continue to have lung involvement for quite some time even after discharge from hospital. On top of that, if they have so much polluted air, the problems get worse. So we are advising them to have plants in their room, have an air purifier, so that the impact is, to some extent, reduced. But along with that, we all should start reducing taking out cars by 20-30%. If each person starts thinking that I have to reduce smoke and dust, if each one can start contributing a little to reduce pollution, collectively, I think, we would have made substantial improvement in levels of pollution.
Since we last spoke, doctors like yourself are far more confident of treating COVID-19, though we do not have a cure and we do have a vaccine around the corner. How should those who contract it go about receiving treatment? Do they need to be alert in any different way than before?
The indications for admission today are more streamlined than when we had our last discussion. So, there are clear-cut divisions between mild and moderate cases, who are actually being home-managed with oxygen monitoring. At that time, this term ‘happy hypoxia’ was not well known. We were waiting for some people to develop breathlessness as a sign of their lung involvement, which unfortunately was not true because many people had lung involvement without developing breathlessness and a lot of lives were lost. Today, we understand it better. So, we are proactively monitoring the oxygen levels. And everybody is advised that if there is a fall below 95%, you must report to a doctor, and there are clear-cut guidelines. There are more oxygen centres available in the hospitals, where they can go. And a large number of these patients can be managed with only oxygen, and a good number of these people are improving with oxygen therapy. A very small number actually need a BiPAP or ventilator therapy, which also is available in a more organised manner today than it was when we had our last discussion.
We are still in November. Do you see a long winter ahead for yourself?
Definitely yes. But what I fear and do not want to see is a massive spike in the number of COVID-19 cases. My fear is, if this deadly cocktail--the festivities which will occur over the next few days, coupled with the steep rise in pollution--has an effect on COVID-19 and we see a massive spike, it will be disastrous for the people as well as for the healthcare sector because the ICUs are almost choked, at least in all Delhi hospitals. And on top of that, if there is a massive increase in the number of patients, then we have a serious problem at hand. And as a doctor I would like to see it prevented rather than face the unfortunate situation.